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ABDOMINAL TflWjmOH 




LIBRARY. OF CONGRESS. 

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UNITED STATES OF AMERICA. 



TREATISE 



ON 



Abdominal Palpation. 



.A. TIRIE^T'ISIE 



ON 



Abdominal Palpation, 



AS APPLIED TO OBSTETRICS, 



AND 



Version by External Manipulations, 



By A. Pinard, 



Associate Prof, in the Faculty of Medicine of Paris, Former 
Chef of the Obstetrical Clinic; Knight of the 
Legion of Honor, &c. 



WITH 29 WOODCUTS INSERTED IN THE TEXT. 



PARIS, 1878. 



Translated by L. E. NEALE, M. D., 

Chef of the Obstetrical Clinic and Demonstrator of Obstetrics in 
the University of Maryland. 



I 

NEW YORK: % ..^ 

J. H. VAIL & CO., 
21 Astor Place. 

1885. ' 



.■■PCA- 




Entered according to the Act of Congress, in the year 1885, 

By L. E. Neale, M. D., 
in the Office of the Librarian of Congress, at Washington. 



PREFACE, 



Although the classic work of Pinard was in my hands before 
I left this country, I had no positive idea of the facility, the 
utility and the certainty of diagnosis by Palpation, until I found 
it constantly and successfully proved during my stay in Ger- 
many, where it has been and is so generally employed and 
universally known, that it is not deemed requisite to include any 
detailed account of the procedure in systematic works on 
obstetrics. 

Since my return, engaged in teaching practical obstetrics for 
two years, I found no work in English, to which I could refer 
my students, in order to follow my instructions. 

In all the text -books the subject was mentioned in the most 
cursory and unsatisfactory manner. 

There was no methodical work in which the whole subject 
was considered in connection with diagnosis and the correction 
of mal-presentations by external manoeuvres, save the published 
results of Pinard's researches in his 100,000 cases. We had the 
publications of Wright, Chadwick, Richardson, Wilson and the 
elaborate and well digested papers of Munde (Amer. Journ. of 
Obstet.), but they were only to be found in journal literature, and 
were consequently not accessible to students as a class. 

I therefore, with the consent of Dr. Pinard, undertook the 
translation and publication of that part of his work concerning 
external diagnosis and manipulations, for the use of my class, 
and also that the younger members of the profession might have 
the opportunity to study and appreciate so important a part of the 
obstetric art. Dr. Pinard not only kindly authorized this, but 
generously offered the use of his plates, for which I here make 
my acknowledgement. The publisher however procured the 
cuts from Baltimore artists, which do not compare unfavorably 
with the original. 

The subject being. so purely demonstrative, the translator has 
felt it his duty to make his work as literal as possible. 

Dr. NEALE. 



Paris, 26, Rue Cambon. 
Monsieur et cher Collegue : 

Permettez moi, tout d'abord, de vous remercier des apprecia- 
tions si flatteuses que vous portez sur mon traite du Palper 
Abdominal. Je vous donne toute l'autorisation necessaire pour 
traduire mon livre. 

Si vous avez besoin des figures, vous pourrez vous adresser 
a mon editeur qui vous livera les bois. 

Je n'ai rien publie dans le texte de l'ouvrage du Professeur 
Tarnier, ni dans aucun ouvrage francais devant ttre traduit en 
langue-anglaise. 

En vous remerciant encore, et en vous priant de me donner 
Toccasion de vous etre agreable, je vous prie d agrier, mon cher 
collegue, l'expression de mes meilleurs sentiments. 

PINARD. 
Dec: 26th, 1884. 



Abdominal Palpation as applied to the 
diagnosis of pregnancy. 



Since Rcederer (i) directed the attention of obstetricians to 
abdominal palpation, by showing the valuable advantages that 
may be derived from it, in connection with the diagnosis of 
pregnancy, nearly all authors have mentioned this method of 
exploration ; but I may say, that vaginal touch and auscultation 
alone have been described by them with any degree of 
thoroughness. 

Without desiring to detract in the least from the very precise 
results, that may be obtained by the aid of these two methods 
of exploration, as applied to the diagnosis of pregnancy, I be- 
lieve that the external examination will also often render great 
service, and should therefore, be described more in detail than 
is observed in most of our classic works. 

As applied to the diagnosis of pregnancy, palp'ation has for 
its object to reveal the presence of a tumor in the abdominal 
cavity, and moreover, to make known the nature of its contents. 

EXAMINATION OF THE UTERUS BY PALPATION. 

It is absolutely necessary, before practicing palpation to 
empty both bladder and rectum. The woman lying down in 
the position described on page 12, after having appreciated the 
thickness, the degree of tension and the sensibility of the ab- 
dominal wall, one should seek the presence of the tumor. 
At this point, let it be well understood, percussion may render 
valuable service, but, I shall not delay with that method of 
exploration. 

In certain cases, where the size of the tumor is marked, it 
immediately presents itself to the examining hand and nothing 

1. "Koederer," Elements of the art of obstetrics. Page 74, translation 
Paris, 1765. 



remains but to appreciate its contour, and its consistence. This 
condition exists when the pregnancy is well advanced, or where 
the neoplasm is well developed. 

When, on the contrary, the tumor is less marked in the 
hypogastric region and is partly concealed in the cavity of the 
small pelvis, its discovery may be attended with considerable 
difficulty. 

In this case it is well to tell the woman to breathe deeply 
while the examiner makes pressure with the two hands applied 
flat over the abdomen. 

L y gently continuing this pressure, he gains a little with each 
expiration, till he is finally able with considerable facility to ex- 
plore the large pelvis and the region of the superior strait. 

Sometimes the hands applied in this manner may penetrate 
deep enough to touch the sacro -vertebral angle, which, without 
due caution, may be mistaken for a pathological tumor. 
During my internship in the service of my excellent teacher, Dr. 
Woillez, I witnessed such an error. 

The tumor once recognized, what is its nature ? 

Is it possible by merely palpating the tumor, and without 
knowing the nature of its contents, to declare that it is the uterus ? 

Notwithstanding the assertion of certain authors, I think not, 
and for the following reasons. 

These authors say that when you have marked out an 
abdominal tumor, and that tumor alters its consistence, contracts 
and hardens under the hand, you may safely assert that it is 
the uterus, for no other tumor, whatsoever be its nature, can 
offer these peculiarities, 

I believe that this assertion is too positive, for on the one 
hand the bladder, enormously distended with urine, may con- 
tract, as has been observed by my two teachers, Pajot and 
Tamier, upon a woman admitted into the hospital clinic for re- 
troversio uteri gravidi. 

On the other hand a subperitoneal fibroid attached to the 
uterus by a slender pedicle may harden under the hand, as I 
have on two occasions most distinctly observed. 

The external exploration of the tumor, then, will only give 
the probabilities, the internal exploration alone will give a 
certainty. 



This exploration of the contents may be either direct or in- 
direct : direct, when one introduces a finger or an instrument 
into the cavity itself through the os ; indirect, when one seeks 
either by auscultation to hear the fcetal heart sounds, or by vagi- 
nal touch or abdominal palpation to discover the active or 
passive movements of the body contained. 

Here, I shall speak only of palpation. 

Now, that it is generally and justly admitted that the passive 
movements of the foetus constitute one of the three certain 
signs, since gravid uterus during the latter third of gestation 
and sometimes during the second half is the only abdominal 
tumor in which one may distinctly perceive the presence of 
a solid body movable in a liquid ' (i), one understands the im- 
portance that is attached to all means which may furnish this 
sign. (2) 

To be sure, if the tip of the index finger be placed in front of 
the cervix uteri and suddenly depresses the uterine wall at that 
point, it may often be easy to perceive ballottement, i. e. the 
sensation of a solid body which recedes and returns, producing 
a light tap on the finger. But just in those cases where this 
manoeuvre gives only negative results, palpation may be more 
serviceable. 

One may obtain ballottement as follows : the tumor being 
well mapped out and the hands placed on each side of the 
uterus, by depressing, a little sharply the uterine wall with one 
hand while the other steadies it on the opposite side, the sensa- 
tions perceived may be various. Sometimes the depressing 
fingers perceive a solid body which recedes and there is no 
other sensation ; again, the depressing fingers may feel nothing, 
while the hand placed on the opposite side experiences a gentle 
tap produced by the body which being displaced has directly 
struck against the uterine wall at that point. 

It has several times occurred in my experience to observe 
these different sensations during the third and fourth month of 
pregnancy ; but it is not after this fashion that one generally 

1. Des causes d'erreur dans le diagnostic de la grossesse, by Prof. Pajot. 
Annales de gynecologie, 187 4. T. I , p. 188. 

2. The only tumor which can give the same sensation, is the foetal sac 
of an extra uterine pregnancy. 



IO 

obtains ballottement "; it is when the fundus of the tumor is at 
or near the umbilical region, which of course necessitates a con- 
siderable development of the uterus, that true ballottement 
may be best felt externally, and I do not hesitate to say, almost 
as easily as by vaginal touch. 

In that region the thickness of the abdominal wall is con- 
siderably less than elsewhere, and the uterine wall being there 
fore separated from the examining fingers only by a very small 
interval, by gently tapping with the finger tips one obtains the 
single or double rebound, very distinctly. Just, as when ex- 
amining the uterus by vaginal touch for this purpose, we select 
the anterior cul-de-sac, I think that when examining by palpa- 
tion, we should select the region about the umbilicus. 

Finally, the hand applied mediately over the uterine wall, 
may perceive the foetal shock, i. e. the active movements ; a 
sign obtained earlier than ballottement, as was first shown by 
Prof. Pajot, by the aid of ausculation ; which sign, shows not 
only the presence but also the life of the fcetus. 



Abdominal palpation as applied to the diagnosis 
of presentations and positions. 



Preliminary preparations. — To practice palpation the wo- 
man should be in the dorsal decubitus. 

Although we can generally explore the whole abdomen when 
the woman is protected by her garments," by taking care to 
raise these as high as the epigastrium," it is better in practicing 
palpation that she be upon her bed clad only in her chemise. 

In truth, the garments being drawn up, not only may they 
become a source of discomfort to the woman herself, but often 
hinder the explorer in examining the fundus uteri, particularly 
in those cases where the organ has attained such a degree of 
development and of elevation that its fundus is concealed under 
the false ribs. The corset produces the same inconveniences. 
I have moreover noticed in these cases, that despite all our pre- 
cautions, there is produced by the rolled up clothing or the 
corset, a constriction around the abdomen, or lower part of the 
thorax, that hinders the free play of respiration; there then 
follows an acceleration in the respiratory movements, and as 
each inspiration stretches the muscles of the abdominal wall, 
there is only a very short complete relaxation during expiration, 
and on that account the examination is rendered more difficult. 

The decubitus should be as horizontal as possible. During 
the latter period of pregnancy nearly all women experience 
relief, especially with regard to respiration, by reclining with the 
head high and propped up by several pillows. This is a bad 
position for practicing palpation ; the contents of the abdominal 
cavity have a tendency, especially in multiparas, to sink towards 
the inferior region of the abdomen, lying over upon the sym - 
physis pubis and sometimes even passing below it ; and it is 
therefore in some cases extremely difficult or even impossible 
to explore the cavity of the small pelvis. One should then re- 
move the pillows and permit the head to rest upon the bolster, 



12 

or upon one pillow only, should the simple horizontal position be 
too uncomfortable. 

Nearly all, if not all authors advise that the legs be flexed 
upon the thighs and the thighs upon the abdomen. 

This precaution is bad in all respects and for the following 
reasons : the object in view by flexing the lower extremities is 
the absolute relaxation of the abdominal muscles ; but that ob- 
ject is not obtained by this position, far from it ; for the woman 
then having a true purchase, is decidedly more disposed to con- 
tract these muscles, the effort being thereby rendered easier. 

But this is only a secondary matter ; of more importance is 
it to recognize that by flexing the inferior extremities of pregnant 
women, it becomes practically impossible to explore the pelvic 
cavity. Especially during the latter period of gestation, when 
the abdomen is more or less prominent and this semi-flexion 
brings the anterior face of the thighs against the abdominal 
wall, it is absolutely impossible to find certain diagnostic points, 
or in a word to examine the excavation. 

So far from having the inferior extremities flexed, I think it 
is decidedly preferable to have them extended, and slightiy 
separated, in order that the horizontal rami of the pubes may 
be more easily explorable. 

Is it necessary to explore the abdominal wall nude, or may 
one practice palpation with the abdomen covered by the che- 
mise ? I do not hesitate to acknowledge that while it is often 
possible, indeed easy, by palpation practiced upon an abdomen 
covered by the chemise, to make the diagnosis of both presen- 
tation and position, it is at the same time infinitely better to 
practice this mode of exploration upon an abdomen entirely 
nude. 

To recapitulate, I believe the very best position in which it is 
possible to place the woman is the following : horizontal dorsal 
decubitus, head slightly flexed, arms lyi?ig alongside of the 
trunk, inferior extremities extended and a little separated, the 
abdo7nen uncovered from the pubic to the epigastric region. 

It is useless to insist upon the point, that the woman should 
not lie in the middle of the bed, but should be near the edge, in 
order that the examination may not be too severe for the woman 
or too fatiguing for the operator. 



13 

It should likewise be remembered that very often, even at the 
beginning of the examination, the uterine muscles may contract 
( painless contraction of pregnancy) and the hand find nothing 
but a globe as hard as wood, which can not be depressed at 
any point on its surface. 

We should then wait, and after a little while, rarely exceed- 
ing a few minutes, the uterus will enter into a condition of 
relaxation, in which state alone can the examination be made 
with fruitful result. Finally, I can not too much insist 
upon a detail of very great importance : I desire to speak of the 
temperature of the hands of the examiner. Nothing is more 
disagreeable to the woman than the application of cold hands 
to the abdominal wall, besides, the sense of touch is less acute, 
as everyone knows, when the hands are not sufficiently warm. 



Method of Examining. 



One may stand indifferently to the right or to the left of the 
woman, but it is necessary that the accoucheur should stand 
at about the height of the umbilicus. 

One should then examine the thickness of the abdominal 
wall, for the sensations preceived will be more or less distinct 
and superficial, just in proportion as the abdominal wall is 
more or less thick. 

This examination is very easily made in all cases ; it is 
only necessary to catch up a fold qf the wall, and the thick- 
ness of this fold will inform us sufficiently. At this moment 
palpation really begins. 

Where should one begin to palpate ? 

Should one seek indifferently any part of the foetus : and 
place the hands either above or below ? 

Nearly all accoucheurs who use this method of examina- 
tion, advise, to begin by seeking the head ; others say, first 
map out the uterus, depress its different parts indiscrimi- 
nately from above downwards, or from below upwards, from 
right to left or from left to right and then analyze the sensa- 
tions perceived, and finally arrive at a diagnosis* by syn- 
thesis. 

These different methods of examining present great incon- 
veniences, and every time I have made the students palpate 
without giving them other rules, I have seen them misled 
and make false diagnoses. Indeed, it is hard to understand 
why this should not be so; the head does not always con- 
stitute a fixed sign ; it may be deeply engaged in or situated 
immediately above the superior strait. The planes of resis- 
tance may be found in nearly every part of the abdomen, as 
is shown in the diagrams of this chapter. Therefore, in 
analyzing with care the sensations perceived, it is only with 
difficulty that one can mentally see the foetus in utero. That 
those accoucheurs accustomed to practice palpation, do rec- 



15 

ognize the various attitudes of the foetus during the latter 
period of pregnancy, and i:re able to make an exact diag- 
nosis after the above method, can not be doubted ; but at 
the same time, they well recognize the fact that it requires a 
long experience to arrive at such a result. 

For these reasons I have endeavored to simplify the method, 
to render it rational, and make it rest entirely on the exact 
knowledge of the various attitudes the foetus may assume during 
the last month of gestation ; z. e. the accommodation. 

Thus, attentive observation has shown that at the time of 
labor only certain parts of the foetus can present at the superior 
strait, and not any part as was thought for so long a time ; 
we now know that during pregnancy the product of conception 
obedient to physical laws, takes determinate attitudes, is gov- 
erned by determinate causes, and not by indifferent and acci- 
dental circumstances. 

The touch, in relation to the diagnosis of presentations 
and positions did not become either possible, easy or precise, 
until the close of the epoch when the labors of Lachapelle, 
Dubois and Nsegele destroyed the table of ancient ideas and 
simplified the classification of both presentations and posi- 
tions. Before that period, and indeed even during the time 
of Baudelocque, the obstetrician upon introducing his finger 
in the genital tract, was obliged to confront himself with 
this question : which one of the 6 presentations and the 
1 02 positions shall I find ? 

To day, the method of examination has become relatively 
easy, so that the student knows the finger can only meet 
with three parts of the foetal body, with their two varieties and 
four positions. 

But palpation is not so easy unless one has some idea 
of the normal or abnormal situations the foetus may take 
towards the end of gestation. 

Knowing that the cephalic extremity should be found in 
the pelvic excavation (all conditions being physiological,) it 
is then that region which should be first examined. There 
is still another advantage in this method, viz : the diagnostic 
marks of the mother instead of the foetus, are fixed. 



i6 



EXAMINATION OF THE EXCAVATION. 



It is necessary to find the pubis and its horizontal rami, 
i. e. the superior opening to the excavation or the anterior 
part of the superior strait, (see Fig. ]). 

It is absolutely indispensable to recognize this point, as it is 
only after this, that it will be possible to appreciate the degree 
of engagement of the fcetal part, which will be more or less 
marked, according as the presentation is found above or 
below this point 

In nearly all women, it is quite easy to find with the ex- 
tremitv of the fingers the superior border of the anterior 




Fig. 1, — Position of the hands at the beginning of the examination 
of the excavation. 



: 7 . . 

curve of the pelvic brim ; with some, and particularly with 
those who have the abdominal wall thin and extensible, and 
the uterus in anteversion, the pendulous abdomen, or even 
with those who have a very pronounced inclination of the 
superior strait, an anteversion of the pelvis, it becomes necessary 
first to raise up the sagging abdomen with the palms of the 
hands, and then to seek the points above indicated. 

The examiner should then interrogate the excavation. For 
that purpose, placing the hands about five or six centimetres 
to the right and left of the median line, the extremities of 
the fingers being in relation with the anterior curve of the 
pelvis, he depresses the abdominal wall from above downwards 
and from before backwards, just grazing over the horizontal 
rami of the pubes, (see Fig. i). 

When properly palpating, only two sensations may be 
perceived, viz : the fingers experiencing a sensation of resis- 
tance, resulting from contact with a hard, round, and volumi- 
nous body which fills the excavation, can not penetrate deeper ; 
or, on the contrary, they only meet with the resistance offered 
by the soft parts, and can therefore sink more or less deeply 
into the excavation. 

In the first case the pelvic excavation is full, in the second 
it is empty of the fcetal parts. Let us examine the two cases : 
excavation full and excavation empty. 

Excavation Full. 

The body that one finds always presents the following 
characters : it is round, regular, resisting and fills, either en- 
tirely or partly, the pelvic excavation. These characters can 
belong to the cephalic extremity only ; again, palpation being 
practiced during gestation, i. e. before the commencement of 
labor, it can only be the flexed cephalic extremity, the vertex, 
that presents, for during gestation, one never meets with the 
cephalic extremity extended, (the face), the breech, or the 
trunk. 

Of the five parts of the foetus that may offer, before labor, the 
vertex alone engages. By reason of the anatomical conforma- 
tion and the volume of the other parts, it becomes necessary 
and indispensable for the production of their engagement, that 



i8 

there exist strong and frequent contractions ; and these do not 
appear except during the pains of labor and never during ges- 
tation. 

Hence the first point of extreme importance. The fixed and 
essentially practical deduction from this simple fact, of knowing 
that in a pregnant woman not in labor, there is but one fcetal 
part that sinks into the excavation, is the following : the prese?i- 
iation is that of the vertex ; moreover, this extremity engaged 
in the pelvic canal has still another significance none the less 
important : it shows that the presentation is fixed and definite. 
There then comes into relation, the coincidence of the three 
axes, viz : the fcetal, uterine and pelvic ; and it is no longer possi- 
ble for the foetus to leave the situation that it occupies or for the 
head to abandon the small pelvis to reascend into the great ab- 
dominal cavity ; in a word, the change of presentation is im- 
possible, variations of position alone may occur. 

Secondly. When the vertex is engaged, the cephalic tumor 
is always more accessible, more prominent on one side than o?i 
the other; thus, when the fingers of one hand can descend more 
or less into the excavation, the fingers of the other will be an 
rested sooner at a point near the superior strait, {see fig. 2). 
That portio?i of the cephalic sphere which is more prominent, 
more accessible, more elevated, is formed by the frontal region- 

From the exact knowledge w r hich we now possess, of the 
mechanism by which the foetus enters into and traverses 
the pelvic canal, we know that the head can engage only when 
it is flexed ; then in proportion as the occiput descends, the 
brow rises (the occipito mental diameter see-sawing and finally 
engaging by one of its extremities), in such a manner that 
when as in primiparae, the head carrying with it the inferior 
uterine segment is sunk and fixed in the excavation, whilst rest- 
ing on the pelvic floor, the brow is still accessible at or a little 
below the superior strait. 

When the engagement is less pronounced, when the occiput 
is directed posteriorly and when, as every one knows, the flexion 
is far from being complete, the difference in height between the 
brow and occiput is still distinctly perceptible. 

At the same time I may also add, that the frontal region is 
not only more elevated, but moreover seems harder to the hand 



19 

than the occipital. Thus, does this simple discovery suffice to 
establish simultaneously and immediately the diagnosis of both 
presentation and position. To sum up : in vertex presentation — 
cephalic tumor more accessible on the right : position left ; ce- 
phalic tumor more accessible on the left : position right. 




Fig. 2. - The hands exploring the excavation. The right hand 
arrested by the brow on the right side. 

The inferior extremity of the fcetal ovoid being recognized, 
we should then seek the superior extremity. This latter will 
nearly always be found in the fundus uteri, it may be, directly 
under the median line or inclined to the right or left. In examining 
this extremity one feels the sensation given by a body volumi- 
nous, irregular, and of less consistence than that of the head, and 
moreover often accompanied by the small parts. Sometimes 



20 

these small parts are, so to say, massed together with the breech 
(the fcetal pelvic extremities remaining flexed) ; sometimes they 
are found more or less distant ; and still again, it is sometimes 
impossible to find them at all, as when the back of the foetus is 
in relation with the abdominal wall. 

Having thus examined the superior extremity of the fcetal 
ovoid, composed in part or entirely of the breech, to establish 
the diagnosis of the variety and the position, or of the position 
and its variety, if the characters I have described as belonging 
to the brow and occiput, have not been sufficiently distinctly 
perceived, one should seek the situation of the back. For this 
we should be careful to observe, while depressing the abdominal 
wall, upon which side is found^he resisting plane of the uterine 
contents, that connects or unites the superior with the inferior 
foetal pole. 

This should be done by the aid of gentle pressure practiced 
only by the tips of the fingers. The sensation perceived is not 
always the same ; generally the back of the foetus is exactly ap- 
plied against the uterine wall, and this against the abdominal 
wall ; in which case the resisting plane seem quite superficial ; 
at other times, when there exists between the back and the 
uterine wall a certain quantity of liquor amnii, the resisting 
plane seems to be situated more deeply, because the fingers 
must displace the intervening fluid. Be that as it may, when 
the back is in front we can, so to say, map it out, but should it 
be behind, we can not touch it, and can then only feel one of the 
lateral planes. 

When we have found the back or the lateral plane on one 
side, we should depress in the same manner the abdominal wall 
on the opposite side, in order that we may obtain a means of 
comparison, to appreciate the difference of the sensation made 
by the fcetal plane or by the elasticity of the liquor amnii. It 
is indispensable to practice this little manoeuvre in order to as- 
sure one's self that there are not several products of conception, 
or neoplasms and especially myomata present. 

Excavation Empty. 

In this case one finds the inferior extremity of the fcetal 
ovoid either above the plane of the superior strait, or in one 
of the iliac fosses. In the thousands of women that I have 



examined, on two occasions only did both extremities of the 
foetus correspond with the maternal flanks, as is shown in figures 
24 and 25 : among all the others, wherever I found the excava- 
tion empty, the inferior foetal pole was discovered either directly 
above the plane of the superior strait or in one or other of the 
iliac fossae. In general, then, one is nearly sure to meet with 
a large extremity in relation with the large pelvis, The other 
extremity is very easy to find, for w r hen one of the iliac fossae 
is occupied by one of the extremities, the other extremity is 
always in the flank of the opposite side. The two extremities 
being- found, the examiner should seek if the head is above or 
below; this differential diagnosis does not present any diffi- 
culty. 

In the first place, each extremity can be recognized according 
to its proper characters, but moreover, a sign which one might 
call pathognomonic will serve to remove all doubts immediately. 
This sign is the ballottement, which is perceived when one im- 
presses on that point of the abdominal wall in relation with the 
cephalic extremity, an impulse or depression somewhat sharp 
(1) (see figure 15). 

We then perceive how this part of the foetus more readily 
recedes from the abdominal wall than does the pelvic extremity ; 
it truly ballots, and that does not occur when we make 
similar pressure over the region of the pelvic extremity. 

This particular mobility of the head results, in part from its 
spheroidal shape which will not permit it to touch the uterine 
wall except by one single point at a time ; in part also, from the 
manner in which it is articulated with the trunk. It is by reason 
of the entirely special manner of articulation of the head with 
the vertebral column, that one can impress upon the cephalic 
extremity, movements which do not extend to the trunk ; while 
if one depresses the abdominal wall over the pelvic ex- 
tremity, this latter can not be displaced without carrying with 
it the trunk ; finally, the different parts composing the breech 
are in contact with the uterine wall by larger surfaces. 

Therefore, it is apparent, the differential diagnosis of the 
locality occupied by the head or breech is in effect sufficientiy 

1. This little manoeuvre is called in German v : Manoeuvre of Valenta. 



22 

easy. The discovery of the back will then enable us to make 
the diagnosis of the position and of the variety. 

In the chapter on the Diagnosis of breech presentation by 
palpatio?i, are shown the difficulties that may be encountered in 
certain cases, (see page 36). 

SENSATIONS FURNISHED BY PALPATION IN THE PRESEN- 
TATION, THE POSITIONS AND THE VARIETIES 
OF POSITION OF THE VERTEX. 



Occipito-iliac left anterior. 

The hands find the excavation filled by the cephalic sphere ; 
but on the right side of the pelvis the fingers can not descend 
as deeply as on the left, (see Fig. 3).! 




Fig. 3. — Vertex presentation : Occipto- iliac left anterior. 

To appreciate well the difference in height between the 
occiput and the brow, it is necessary to direct the hand that ex- 



23 

amines on the right side a little behind, towards the sacro iliac 
symphysis, (the antero posterior diameters of the head lie in the 
left oblique diameter of the pelvis). 

The pelvic extremity occupies the fundus uteri, but is gen- 
erally found on the right side. In some primiparse one finds it 
under the median line. 

In multiparae, by reason of the increased transverse diameters 
of the uterus, the breech remains more to the left 

The resisting plane, the back, is situated to the left anteriorly 
while on the right side, we find only the elasticity of the liquor 
amnii, and the small parts. 

These latter may be found as well above as below, for it 
sometimes happens that one perceives both upper and lower 
extremities with equal facility. 

In certain cases ex. gr. in women who have already borne 
several children and consequently possess a certain laxity of 
the abdominal wall, although the head may have penetrated 
into the excavation, the trunk acquires only a semi-accommo- 
dation, i. e. the back traverses the abdominal wall diagonally, 
the breech resting in the right flank, while the shoulders are in 
the left iliac fossa. A straight line drawn from the right flank 
towards the left iliac fossa would represent very well the direc- 
tion of the resisting plane. 

This is a first degree of non-accommodation which is shown 
only in cases of anterior obliquity of the uterus (pendulous 
abdomen), ["ventre en obusier, en besace, etc."] 

Occipito - iliac right posterior'. 

The hands find the excavation filled by the cephalic sphere, 
but the fingers can not penetrate as deeply on the left side as on 
the right. Although in posterior varieties the flexion is less 
pronounced than in the anterior, the difference in height be- 
tween the brow and the occiput is still w r ell marked, and is 
easily perceived, because the brow being situated in front, in 
relation with the ilio-pectineal eminence, it presents itself, so 
to say, to the hand, while the occiput remains concealed behind 
and to the right. 

The breech is in the fundus uteri, generally on the left side, 
although sometimes under the median line. The resisting plane 
is to the rio^ht, but offers less surface than in the anterior varieties. 



24 

We can examine but little else than the left lateral plane of 
the foetus, and not the back. Generally the left shoulder is 
found about 7-8 centimetres from the median line. 

On the left side we find only the elasticity of the liquor 
amnii and the small parts more easily accessible than in the 
anterior varieties. 



Fig. 4. — Vertex presentation : Occipto-iliac right posterior. 

Occipito -iliac right anterior- 

The excavation is filled by the cephalic sphere, but the hand 
penetrates more deeply upon the right than upon the left side. 
The breech is in the fundus uteri, generally on the left side. 

The plane of resistance occupies the entire right side of the 
abdominal wall. The left side of the foetus is in relation with 
the linea alba. The surface of the resisting plane is decidedly 
more considerable than in the posterior variety. By placing one 
hand on a level with the median line, and the other behind and 
to the right, we can, so to say, map out the back, (see Fig. 5). 



25 

On the left side is found only the elasticity of the liquor amnii 
and the small parts. 




Fig. 5. — Vertex presentation. Occipito-iliac right anterior. 

Occipito -iliac left posterior. 

The excavation is filled by the cephalic sphere, but the hand 
penetrates deeper on the left than on the right side. The breech 
is in the fundus uteri generally to the right. The plane of resist- 
ance is on the left side but offers less surface than in the anterior 
varieties. We can examine but little else than the left lateral 
plane of the foetus and not the back. The right shoulder is 
found about 7 to 8 centimetres from the median line. 

On the right side is found only the elasticity of the liquor 
amnii, and the small parts very easily accessible. 

Occipito-illac transverse. 

During gestation, I have never found the transverse variety 
except in two classes of women ; i° in those presenting a very 
pronounced anterior obliquity of the uterus ; 2° in those whose 
pelvis deformed by rachitis was contracted antero-posteriorly 
(flat pelvis). In the former the head being engaged in the exca- 



26 

vation is difficult to find unless one takes certain precautions, 
already mentioned, which consist in elevating or redressing the 
abdominal wall during the examination of the diagnostic points. 



Fig. 6. — Vertex presentation : Occipito-iliac left posterior. 

The superior border of the pelvic canal being found, the cephalic 
tumor is then very easily perceived, more accessible on one side 
than on the other. But if the hand is carried up over the fundus 
uteri, which is relatively low, it does not meet with either large 
or small extremities. 

The breech is found in or above one of the iliac fossae, always 
on that side where the cephalic sphere is more accessible. 

It has often occured to me to find the feet a little distance 
above the brow, (see Figs. 7 and 8). The resisting plane is directed 
neither anteriorly nor posteriorly, but is situated transversely. The 
trunk of the foetus curved upon itself represents an arc of a circle. 
The elasticity of the liquor amnii is found both above and below 
the resisting plane. If one does not know this particular accom- 
modation of the trunk of_the foetus, it is extremely difficult to 
recognize it and on that account to make the diagnosis- Practi- 
cally one finds a resisting surface as well on the right side as on 



27 




Fig. 7. — Vertex presentation : Occipito-iliac left transverse, 
fin those cases where the uterus falls forward.) 




Fig. 8- Vertex presentation : Occipito-iliac right transverse. 
(In those cases where the uterus falls forward.) 



23 



the left ; the elasticity of the liquor amnii is perceived as easily 
above as below ; the uncertainty is great and hence the frequent 
erroneous diagnoses. Knowing, however the attitude of the foe- 
tus in these cases, we will, on the contrary, arrive at the right con- 
clusion. 




Fig. 9. — Vertex presentation: Occipito-iliac left transverse. 
(Pelvis deformed by rachitis.) 

In those women having a pelvis deformed by rachitis, when 
the head is below, it may be found on a level with the plane of 
the superior strait, or somewhat engaged and generally slightly 
flexed; sometimes it is still possible, at the same time to 
recognize upon which side the brow is found by reason of its 
greater elevation, but especially on account of its very marked 
hardness. 

If the uterus be not anteverted, the breech occupies the 
fundus uteri. The resisting plane is directed neither anteriorly 
nor posteriorly, but exactly towards the right or the left side, 
according as we have to do with the one or the other position. 



2 9 

Here it is not the form of the abdominal or uterine cavity, 
that determines the situation of the back, but it is the head 




Fig. 10. — Vertex presentation ; Occipito-iliac right transverse. 

(Pelvis deformed bv rachitis.) 

i 

itself, which is called upon to accommodate its greatest 

diameters (antero posterior), with the greatest or transverse 

diameters of the pelvis. 

SENSATIONS FURNISHED BY PALPATION IN THE PRESEN- 
TATION, THE POSITIONS AND THE VARIETIES 
OF POSITION, OF THE FACE. 

I have never seen a face presentation during pregnancy. 
Three times have I had the opportunity of examining women 
during pregnancy, in whom the children have presented by the 
face at the moment of labor. 



3° 

In the first a in-para examined before the commencement of 
labor, I found the head not yet engaged, but quite prominent 
just above the plane of the superior strait and presenting in a 
situation intermediate between flexion and extension. The 
somewhat voluminous foetus was very movable. What was the 
cause of extension just at the moment of labor? 

I do not know, but I can affirm that at the time of the exami- 
nation, which was made a few hours before labor began, the head 
was not in the least extended. 

In the second, I assisted in the production of the presentation. 
It was a rachitic woman whose pelvis at the brim measured only 
8 centimetres in the conjugate diameter. Labor was induced by 
the use of Tarnier's "excitateur." The head was down but freely 
movable above the superior strait- When there was sufficient 
dilatation of the os, the head not engaging, forceps were applied 
upon the head, not flexed, it is true, but not extended. After 
several fruitless tractions the instrument was removed and a pres- 
entation of the face was diagnosed both by palpation and touch. 

In these two instances, the possibility of the presentation was 
attributed to the high situation and mobility of the head. 
As to the accidental causes, it was produced only under the 
influence of the contractions of labor in the first case, and under 
the possibly mal-directed traction in the second. 

The third case offered a remarkable example of a face pre- 
sentation substituting a vertex presentation, whilst in the pelvic 
cavity. I had examined the woman for the fourth time during 
gestation, on the evening preceding her labor : by palpation I 
recognized a vertex presentation, touch only confirmed this 
diagnosis, for the cervix being quite dilated, I could very readily 
feel the sagittal suture and the two fontanelles. Labor set in 
during the night, and the child was born spontaneouly, pre- 
senting by the face ; it weighed 3,000 grms. 

The explanation of this abnormal occurrence, was afforded me 
by the mensuration of the cephalic diameters, which I found to 
be as follows : 

Occipito-frontal diameter 11 c. m. 5. 

Occipito-mental " 12 

Bi-parietal " 10 

Sub-occipito-bregmatic diameter 10 



3i 

Altogether the head presented the configuration of a ball ; 
moreover, the length of the occipito-mental diameter did not 
exceed 1 2 centimetres, i. e. the length of the diameters of the 
excavation rendered possible this turning of the occipito-mental 
diameter in the pelvic canal. Among all the other cases where 
I could practice palpation, in face presentations, the women 
were more or less advanced in labor ; nevertheless palpation 
was generally easy. 

Though it be true indeed, that in these cases palpation may 
be of less diagnostic value, because by vaginal touch we can 
nearly always, directly feel the fcetal parts, it is also none the 
less true, that we may be somewhat embarrassed even after 
having had recourse to that method of exploration, especially 
when the presentation is only with difficulty accessible, and can 
not be examined over a large part of its surface. It is for this 




Fig. 11. — Presentation of the face, mento-iliac left anterior. 
(Presentation at the commencement of labor.) 



32 

reason I think I should present somewhat in detail the sensa- 
tions perceived by palpation in these conditions. 




Fig. 12. — Presentation of the face, mento-iliac right posterior. 
(Presentation at the commencement of labor.) 

In presentation of the face, the -examination of the excavation 
enables us to recognize the presence of a large tumor, at, or 
above, or below the superior strait, according to the period of 
labor at which the examination is made. Moreover, this tumor 
seems to occupy but one side, or rather only a part of the small 
pelvis : very round, large, and accessible on one side, it appears 
to be wanting entirely on the other. Passing the hand then to 
the fundus uteri, we find, generally on the side where the pelvic 
tumor is more prominent, the breech, recognized by its 
peculiarities. To thoroughly trace out and appreciate the re- 
sisting plane, we should depress the abdominal wall slowly and 
deeply, for this resisting surface seems to sink in the abdominal 
cavity, while the superficial small extremities readily present 



33 

themselves to the hand ; this condition of things results from 
the bending of the fcetus on its dorsal plane. 




FrG. 13. — Presentation of the face, mento-iliac left posterior. 
(Presentation at the commencement of labor.) 

When palpating properly, we may quite readily examine 
one of the lateral planes, and do not fail to recognize that the 
more accessible part of the cephalic sphere is in relation with 
the back ; moreover between the back and the head, especially 
when the labor is well advanced, there is a depression into 
which the fingers may at times easily penetrate. Thus, the 
presence of the cephalic extremity at the superior strait, the 
prominence of that extremity at certain parts of the pelvis, and 
the back in relation with that prominence are the sensations 
perceived which enable us to make the diagnosis. 

According to Dr. Budin, in certain cases, upon the side 
opposite to the accessible tumor, we may feel a prominence, 
having the form of a horse-shoe, distinctly characteristic of and 
constituted by the inferior maxilla and the chin, (i) 

1. Budin, De la tete du fcetus. Th. de Paris, 1876, pp. 51. 



34 



The pathognomonic sign of this presentation as obtained by 
palpation, consists in the presence of the accessible portion of 
the cephalic extremity and the back upon the same side. 




Fig. 14. — Presentation of the face, mento-iliac right anterior. 
(Presentation at the commencement of labor.) 

The diagnosis of the presentation, and of the varieties of the 
position, correspond exactly with those of the vertex, according 
to the anterior, lateral, and posterior situation of the occipital 
region and the back. 

But I repeat, this examination has no importance, except 
when the high position of the presenting part renders vaginal 
touch difficult or impossible. Ordinarily, the dilatation of the 
os, and the engagement of the fcetal part, render the results by 
touch more immediate, and indeed, I may say, easier than by 
palpation. 



35 

SENSATIONS FURNISHED BY PALPATION IN THE PRESEN- 
TATION, THE POSITIONS AND THE VARIETIES 
OF POSITION OF THE BREECH. 



Presentation. — In cases of breech presentation when exam- 
ined during gestation, the hands find the pelvic excavation 
empty. More than this, it may only be possible to find the 
small parts at the level of the superior strait. Above the su- 
perior strait we may distinguish the presence of a large extrem- 
ity in relation with the false pelvis. 



r^wm 








mm- v ; 



\ [ 
/ \ 
/ v 



Fig. 15. — The hand depressing the abdominal wall to obtain the 
sensation of cephalic- ballottement. 



36 

I may here remark that the breech is rarely over the open- 
ing of the superior strait ; it is nearly always found partly in 
relation with one of the iliac fossae and partly over the brim. I 
do not insist upon the palpable characters of this extremity ; it 
will suffice to say that it always appears voluminous, and that 
sometimes the small parts are quite accessible, whilst at others 
they are concealed from examination. 

The head is at the fundus uteri, generally inclined to that 
side opposite the iliac fossa occupied by the breech. When 
the head is situated directly under the median line, it may be 
readily mapped out, and its characteristics appreciated with 
great distinctness ; moreover, it is very easy to produce and 
perceive ballottement, by making a slight, sharp depression 
over the abdominal wall in relation with the head. 

But it is not always so ; for sometimes the head is deeply sit- 
uated, and we have no power over it whatever ; and at other 
times it may be completely hid under the false ribs. This is 
especially observed among primiparae in those breech presen- 
tations which I term "frank" when the uterus, being laterally 
compressed, developes altogether in its longitudinal diameters, 
In such cases we should move the foetus, or make it gradually 
change its position, by pressing inversely upon its two poles, or 
only upon its inferior pole if the superior one is inaccessible, in 
such a manner as to place the head under the median line, or on 
the contrary to make it descend a little lower towards one side ; 
in a word, it should be rendered more superficial, and at the 
same time more accessible, more palpable. 

In fine, I shall insist upon a last point which may be useful, 
and I believe of sufficient importance in connection with the 
differential diagnosis between head and breech. 

When depressing the abdominal wall in relation with the 
foetal trunk, we not only perceive the resisting plane of 
the body contained within, as a connecting surface be- 
tween the breech and trunk, but also a depression, or well 
marked space between the trunk and the head, where the fin- 
gers sink down to the level of the cervical region. 

Positions. — Sacro-iliac left anterior. The left iliac fossa is 
occupied by a large irregular extremity, accompanied or not by 
the small parts : this is the breech. 



37 

The head is at the fundus uteri, but generally in the right 
flank, sometimes quite superficial, very often, however, hid 
away and concealed under the liver. The resisting plane is in 
front, directed from below upwards and from left to right, 
starting from the left iliac fossa and at times rising directly on 
the left side, to curve over towards the right above the umbil- 
icus, at others, being directed immediately towards the right 
flank, traversing the abdominal wall diagonally until it disap- 




Fig. 16. — Presentation of the breech, sacro- iliac left anterior. 



pears and becomes inaccessible about a few centimetres above 
the umbilicus ; but up to that point it is quite easy to circum- 
scribe. 

Sacro-iliac right posterior. — The right iliac fossa is occupied 
by a large, irregular extremity, nearly always accompanied by 
the small parts, which may be felt to the left and in front. 



38 

The head occupies the fundus uteri, generally inclined to the 
left. It is easier to circumscribe than when it is situated on the 
right side. The resisting plane on the right side is directed pos- 
teriorly ; it appears quite narrow, for we can explore but little 
else than the right lateral plane and not the back of the foetus. 

The small parts, and the elasticity of the liquor amnii are 
readily found anteriorly and to the left. 




Fig. 17. — Presentation of the breech, sacro-iliac right posterior. 



Sacro-iliac right anterior. — The right iliac fossa is occupied 
by a large, irregular extremity, which is rarely accompanied by 
the small parts. The head is situated in the fundus uteri gen- 
erally inclined to the left. 

The resisting plane is found on the right side, and is directed 
anteriorly. Starting from the right iliac fossa, and at times 
rising up directly on the right side, to curve over towards the 
left, above the umbilicus, at others it is directed towards the 



39 

left flank, traversing the abdominal wall obliquely. In every 
case it is quite easy to circumscribe it, and to catch it. so to 
say, between the two hands. 




Fig. 18. — Presentation of the breech, sacro-iliac right anterior. 

The elasticity of the liquor amnii is perceived both below to 
the left, and above to the right. The small parts are found to 
the left and behind. 

Sacro-iliac left posterior. — The left iliac fossa is occupied by 
a large, irregular extremity, nearly always accompanied by the 
small parts, which are found to the right in front. The head is 
situated in the fundus uteri, generally inclined to the right 
side, and somewhat difficult to circumscribe. 

The resisting plane is felt on the left side directed posteriorly ; 
it appears quite narrow, for we can explore but little else than 
the left lateral plane and not the back of the foetus. The small 
parts and the elasticity of the liquor amnii are readily found 



4 o 



anteriorly and to the right. This elasticity can be equally well 
perceived at the fundus uteri to the left. 




Fig. 19. — Presentation of the breech, sacro-iliac left posterior, 

SENSATIONS FURNISHED BY PALPATION IN PRESENTATION 
OF THE TRUNK. 



As I have already said, I have never met with shoulder pre- 
sentations during gestation, except in dorso-anterior positions. 
Relying upon that fact and still more upon the anatomical rela- 
tions of the maternal and foetal parts, I am of the opinion that 
if dorso-posterior positions do occur at all during gestation, 
they are observed only exceptionally. 

Indeed, even during labor these positions are equally rare, 



4i 



as is proved by the statistics of Madame Lachapelle, (i). This 
authoress explains the rarity of these positions as depending 
upon the natural attitude of the fcetus, (2). 

Presentation of the right lateral plane ; left cephalo-iliac or 
left acromio-iliac position. (3) 

During gestation. — The excavation is empty. The hands 
meet with the inferior extremity of the fcetal ovoid (the head) 
under the form of a round tumor, regular and hard, occupying 
the left iliac fossa, and in multiparas often ballotting. 




Fig. 20. — Presentation of the right lateral plane 
(right shoulder) left cephalo-iliac. 

In the right flank, more or less high, according to the devel- 
opment of the abdominal cavity, at times hidden under the 
false ribs, in relation with the inferior face of the liver, is found 

the breech with its characters. The resisting plane extends 

* 

1. Lachapelle, Pratique des accouchernents. Fig. of 1st. and 2d. vols. 

2. Lachapelle, loco citat. Vol. 11, p. 188. 

3. I here give this synonym, because in the figures the relations of 
the head to the iliac fossa are better seen than those of the acromion. 



42 

from the left iliac fossa to the right flank, following a line 
curved towards the region of the large pelvis, and rises up 
above the iliac crest, (see Fig. 20.) Sometimes the resisting 
plane looks directly forwards, and then in exploring the exca- 
vation, it is not rare to meet with a small projection formed by 
the right shoulder, which is found immediately above the 
superior strait, and which seems to sink behind the horizontal 
rami of the pubes. Sometimes the resisting plane is directed 
almost exactly below, and then it is of less extent ; we can ex- 
amine the left lateral plane only. Whichever of these two 
varieties, or rather of these two shades of variety exist, above 
this resisting plane and over the superior extremity of the fcetal 
ovoid, we can only perceive the elasticity of the liquor amnii 
and the sensation of several small parts. 

Duri?ig labor. — As has been well remarked by Prof. Herr- 
gott, when the membranes are ruptured, the foetus being com- 
pressed on all sides, but especially about its two extremities, it 
redresses itself. The two poles of the fcetal stem, approach to- 
wards the median line, and then palpation gives the following 
sensations : The iliac fo^sa is occupied by a large spherical 
tumor, whilst that extremity situated in the fundus uteri is 
drawn towards the median line and the resisting plane is directed 
nearly vertically, although always inclined more to the right than 
to the left side. In fine, the curve of the resisting plane has 
disappeared, and the spherical tumor of the iliac fossa seems 
to articulate at right angles with it. 

Presentation of the left lateral plane : right cep halo-iliac 
position. 

During gestatio7i. — The excavation is empty. The hands 
meet with the inferior extremity of the fcetal ovoid (the head), 
under the form of a round, regular and hard tumor, occupying 
the ? ight iliac fossa and ballotting, especially in multiparas. 
The breech is found in the left flank, more or less high, 
according to the development of the abdominal cavity ,sometimes 
in relation with the false ribs. 

The resisting plane extends from the right iliac fossa to the 
left flank, following a line curved towards the region of the 
large pelvis and then rises up above the iliac crest, (see Fig. 21.) 



43 

The resisting plane looks directly forwards or below, as I have 
already pointed out for the similar presentation of the right 
shoulder. 




Fig. 21. — Presentation of the left lateral plane 
(left shoulder) right cephalo-iliac position. 




Fig. 22. — Presentation of the right lateral plane (right shoulder) right 
cephalo-iliac position. (Presentation at the commencement of labor.) 



44 

Over the entire abdominal region, extending above and 
within the resisting plane, we can only perceive the elasticity 
of the liquor amnii and the sensation of several small parts. 

Du?ing labor. — When the membranes are ruptured, modifi- 
cations in the direction of the trunk are produced, after the same 
manner that I have pointed out above. The resisting plane 
is directed vertically, although approaching towards the median 
line, it still occupies the left side of the abdominal cavity. 

Presentatio?i of the right lateral plane : right cep halo-iliac, 
and of the left lateral plane : left cephalo iliac. 

I shall say but a few words relative to abdominal exploration 
by palpation in these positions, for they are produced only dur- 
ing labor, and the uterus contracting upon itself every instant 
during that period, palpation becomes difficult, sometimes im- 
possible, while vaginal touch may give results decidedly more 
distinct, by reason of the dilatation of the os, and the engage- 
ment of the fcetal presentation which is then somewhat more 
pronounced. 




Fig. 23— Presentation of the left lateral plane (left shoulder) left 
cephalo-iliac position. (Presentation at the commencement of labor.) 



45 

When palpation is practiced in the interval between uterine 
contractions, we find only two things of importance : viz. The 
inferior extremity of the fcetal ovoid under the form of a 
spherical tumor, in one of the iliac fossae, the superior extrem- 
ity, under the form of a large, irregular tumor occupying the 
fundus uteri. 




Fig. 24. — True transverse presentation disappearing 
tit the moment of labor. 

The resisting plane is difficultly accessible, while the small 
parts are superficial and are felt with facility. 

As I have said, in treating of accommodation, the foetus 
curved in the arc of a circle rests in the large pelvis, the head 
and breech being found on each side respectively, immediately 
above the iliac fossae. 

In three cases, one of which was with M. Tarnier, have I 
been able to verify this fact. In this case palpation revealed 
the excavation empty. The resisting plane extended into the 
region of, and above the iliac fossae, while the two extremities 
of the foetus were found, the one in the right flank, the other 
in the left. The differential diagnosis of each extremity is readily 
made, it suffices merely to find the proper characteristics that 



4 6 

belong to the head and the breech, and especially to determine 
which extremity ballots. At the moment of labor these pre- 
sentations change, either into presentation of the shoulder, or 
of the breech, or even of the vertex. 




FiGo 25o — True transverse presentation disappearing 
at the moment of labor. 



DIAGNOSIS OF MULTIPLE PREGNANCY BY PALPATION. 



Upon uncovering the abdomen of a pregnant woman, very 
often the attention is immediately attracted by its appearance. 

The abdominal development appears exaggerated, or the 
supra-pubic region is the seat of a localized oedema, or finally 
one recognizes a bilobed and irregular form of the uterus, even 
when that organ is entirely relaxed. Should these conditions 
not be perceived, there is ctill one thing that I believe will gen- 
erally strike one, who begins to examine by palpation, a uterus 
containing several products of conception ; i. e. the permanent 
tension of the uterine wall. The sensation which one perceives 
although somewhat difficult to describe accurately, is readily 



47 

appreciable to those, who are a little accustomed to this method 
of exploration. Instead of depressing the uterine wall with 
facility, one perceives that this wall is tense and resisting. It 
is a sensation analogous to that, which we experience by de- 
pressing the wall of a bag of caoutchouc distended with fluid or 
air. It is not that soft, doughy sensation, which is perceived 
upon depressing the relaxed uterine wall when the organ is nor- 
mally filled ; neither is it that hard sensation, almost ligneous in 
character, which is felt upon depressing the uterine wall during 
a contraction ; it is a sensation intermediate between this and 
one that is well known to physicians, which is perceived upon 
depressing the wall of a distended cyst. I lay stress upon the 
point, that this permanent tension of the uterine wall is met 
with in two classes of cases only, viz.: multiple pregnancy and 
'hydramnion. Therefore, clinically considered, this sign be- 
comes of veritable importance. Upon the recognition or not 
of this sign, the knowledge obtained by palpation is evident. 
A first fcetal pole, the inferior one, is found either in the ex- 
cavation or in the iliac fossa. A second, or superior one, is 
found in the fundus uteri or in one of the flanks. 

The contained resisting plane, is alike easily found and 
recognized. Up to this point, not inclusive of the sensation 
imparted by the uterus, and the consequently slightly increased 
difficulties to palpation, the signs have thus far been furnished 
by one single foetus ; but upon depressing the abdominal wall 
on the side opposite to the one occupied by the resisting plane, 
instead of recognizing the small parts, we find another large 
extremity, or even another resisting plane. We should, then, 
most carefully explore the two iliac fossae, and the superior 
uterine segment. Generally the two large extremities are 
found either above or below. But at times, it happens in cer- 
tain cases, that we readily arrive at the recognition of the 
presence of four fcetal poles, two inferior and two superior, 
while at other times it is only possible to distinguish three ; 
the fourth large extremity being deeply situated, is concealed 
behind another which lies over it in front. 

It is, then, easy to distinguish two resisting planes, and the 
presence of the small parts in several regions of the uterus at 
the same time. Thus proceeding with gentleness, in order not 



4 8 

to displace the fetus, the presence of two large extremities, 
corresponding with the superior and inferior abdominal regions, 
points immediately to the diagnosis. While appreciating the 
difficulties which may, at times occur and which are due both 
to the tension of the uterus and the cedematous infiltration 
which renders the abdominal wall so much thicker, it is none 
the less true, that a diagnosis made methodically is generally 
very easy. En resume, the large extremities or the poles of the 
fetus, are the parts upon which the examiner should concentrate 
his attention Knowing the laws of accommodation, I consider 
that it will be very simple, when finding the excavation filled 
and one or other large extremity distinctly mapped out in an 
iliac fossa, to deduce therefrom that this is a condition of things 
that does not exist in ordinary pregnancy. 

The examination of the superior uterine segment will then 
readily demonstrate the presence of two large extremities, the 
one more elevated than the other. If the excavation is empty 
and two large extremities should be found in the false pelvis, 
the deduction will be similar. Proceeding after this fashion 
during my service at the maternity, I was enabled to recognize 
and confirm the presence of twins in thirty-two cases. I was 
also able to recognize by palpation a triple pregnancy (the only 
one which I have ever met with) in a woman who, during the 
course of her pregnancy, had come to be treated for inflamed 
varices of the lower extremities. I do not know that the diag- 
nosis of triplets has ever been made during gestation, so, I am 
of the opinion that this observation, which I give in detail, goes 
still further to demonstrate the superiority of palpation over 
other methods of exploration now in use. 

During the services of M. Gueniot under M. Depaul, " F." 
entered the obstetric clinic towards the middle of September, 
when she was about five months advanced in pregnancy, on 
account of enormous varices in the anterior superior part of the 
left thigh. These varices became inflamed and caused great 
suffering. For the first few days following her entrance, atten- 
tion was directed only to the phlebitis, which by simple rest, 
was perfectly cured. But a little later she was examined more 
carefully with regard to her pregnancy, when it was recognized 



49 

that the size of her abdomen was relatively exaggerated for the 
period of her pregnancy. 

Upon interrogation, the woman informed me that her husband 
was a twin, that his grandmother was delivered of twins in her 
forty -second year, and moreover his sister was one of a twin 
pregnancy. Palpation was then practiced with great care ; at 
first I found a small head tending to engage in the excava- 
tion ; very soon another head was distinctly perceived above ; 
two resisting planes were found, one below and to the left, 
another above and to the right, and the small parts everywhere. 
Auscultation repeated very often, only revealed a maximum in- 
tensity of fcetal heart sounds to the left and below, and another 
to the right and above. Vaginal touch demonstrated a small 
head commencing to engage. 

A few days subsequent to my first examination, I could, by 
palpation, distinctly make out three heads, which of course 
indicated the presence of three children in utero. One head 
was in the excavation, a second was in the right iliac fossa 
and still a third above and almost under the median line, but. 
extremely movable. At no time could I find three auscul- 
tatory centres. After this, I repeatedly found at each exami- 
nation the three heads, which were also recognized by some 
of the students, (i.) 

This woman, in whom the last menstrual period had appeared 
from the 15th to the 2:th of April, was delivered on the 1st of 
December following of three boys, all three presenting by the 
vertex. 



SENSATIONS FURNISHED BY PALPATION, IN THE CASE 
OF PREGNANCY COMPLICATED BY HYDRAMNION. 

Whenever the quantity of liquor amnii decidedly exceeds 
the usual amount, not only does the ovoid form of the preg- 
nant uterus become more pronounced, but also does the supra- 

1. However, I was informed by Dr. Budin, that palpation became very 
difficult towards the end of her gestation, on account of the tension and 
oedema of the abdominal wall. 



5° 

pubic region become the seat of an cedema just as marked as 
in the case of multiple pregnancy. When the hands are ap- 
plied over the abdomen, the constant tension of the uterine 
wall is immediately perceived. In methodically exploring the 
excavation, which is still possible, notwithstanding the resis- 
tance of the abdominal wall, one rarely finds the cephalic 
extremity. Usually in 'these cases the pelvic extremity offers 
during gestation, but indeed I may say, that there is no real 
accommodation at all. The foetus, generally small, being con- 
tained in a distended cavity, is not necessitated to take any fixed 
and determined attitude, so that we often find changes of pre- 
sentation extremely frequent and rapid, even up to the very 
moment of rupture of the membranes. It may happen that in 
the examination of the abdominal wall, no distinct sensation of 
foetal resistance is perceived, even when we depress those 
regions generally corresponding with the extremities of the 
foetal ovoid. Nothing is perceived but a sense of elasticity and 
of fluctuation. It is then, absolutely necessary to practice 
palpation with the greatest delicacy, for the slightest pressure 
will displace that part of the foetus in relation with the uterine 
wall. Here the sensation of ballottement is exaggerated, for 
the slightest shock displaces the foetus. It is on this account 
that it is so difficult to hear the pulsations of the foetal heart in 
a case of hydramnion, for the mere pressure of the stetho- 
scope is sufficient to displace the foetus, just as we know it may 
very readily occur, when the foetus is small and the uterine 
cavity spacious. 

Therefore, I insist upon these few points, viz.: that in certain 
conditions palpation carelessly practiced may give only negative 
results, auscultation is likewise barren, and even vaginal touch 
merely enables us to recognize the changes in the neck, and an 
engagement more or less pronounced of the inferior uterine 
segment, which contains nothing but fluid. One can then de- 
termine in a woman who seems to have arrived near full term, 
only signs of probabilities but not of certainty. In exploring 
the abdominal wall over its entire surface, one will always find 
a certain point in relation with the foetus, i. e., at the very be- 
ginning of the examination a resistance is experienced in one 
part greater than in any other, and by gradually pressing over 



5i 

this point a solid movable body, floating in liquid, is felt. This 
sensation may be either single or double, i. e. , it may be that 
of a body which merely recedes from the touch, or recedes and 
soon returns, thereby gently striking against the utero-abdominal 
wall. Thus, the permanent tension of the utero-abdominal 
wall and the cedema of the supra-pubic region are signs com- 
mon alike to multiple pregnancy and hydramnion. But the 
differential diagnosis is generally easy to make. In cases of 
multiple pregnancy, notwithstanding this tension, we can readily 
follow out the fcetal surfaces ; the situation is, if not fixed and 
constant, more or less stable, while the abnormal mobility of the 
foetus, in a woman already in an advanced period of pregnancy, 
will immediately direct us towards the diagnosis. It may occur 
in cases of multiple pregnancy, that the products of conception 
being contained in separate and distinct sacs, we may recognize 
hydramnion of one sac only. Here the fixed position of the 
foetus in the normal sac, and the extreme mobility of the other, 
are quite apparent. This abnormal mobility of one of the 
foetus and the stability of the other, has enabled me in several 
cases to diagnose the separate sacs and give a prognosis favor- 
able in proportion to the normal conformation of the two pro- 
ducts of conception. We are well aware how frequently these 
malformations of the foetus occur in hydramnion. 



SENSATIONS FURNISHED BY PALPATION WHEN THE 
FCETUS IS DEAD AND MACERATED. 



When the foetus dies in the uterine cavity, it undergoes cer- 
tain modifications or rather transformations, which develop in 
proportion to the duration of its retention, prior to its being 
cast off. All its tissues soften and its characteristic form is lost ; 
there is no longer the fcetal ovoid, but a dead, shapeless mass. 
Likewise, the sensations perceived by palpation are altogether 
different from those manifested by the living foetus. But in 
order that this marked and appreciable difference in sensation 
should present, it is necessary that the death should occur at 
least eight days prior to the examination. This was the least 



52 

time in which these changes resulted in two observations where 
I was able to ascertain the date of the death of the foetus, and 
practice palpation every day up to the time of its expulsion, 
which occurred in the first case on the 16th day, and in the 
second on the 23d. During the first few days subsequent to 
death, there is but little alteration in the sensation, especially 
when the foetus is accommodated, i. e., when the head is sunk 
in the excavation. The cephalic resistance is still distinctly 
perceived and it maintains its characters for 5 or 6 days. 

Should it be the pelvic extremity, however, these alterations 
are less marked, but the displacement of the part becomes 
more and more easy ; finally it seems to approach near to the 
cephalic extremity, the trunk curving over or rather being de- 
pressed upon itself. When, on the contrary, death has preceded 
the accommodation, a few days subsequently we find the foetal 
mass heaped together and crowded in the inferior uterine seg- 
ment. 

Thus, when practicing palpation in these conditions, we can 
only make out an indistinct resistance at the level of the exca- 
vation and even upon depressing the inferior uterine segment 
the sensation is the same; while on the other hand in the 
superior segment the resistance of the liquor amnii is very dis- 
tinct. 

An almost horizontal line separates distinctly the region 
where we find the soft, doughy resistance, from that where the 
normal fluctuation is apparent. 



SENSATIONS FURNISHED BY PALPATION IN DEGENERATED 
PREGNANCIES (HYDATIFORM MOLE, VESICULAR DE- 
GENERATION OF THE VILLOSITIES). 



As I have only had one single occasion to palpate a woman 
bearing a vesicular degenerated ovum, I have as yet but little 
experience upon this subject. Here palpation enabled me to 
determine an enormous development of the uterine cavity, 
relative to the supposed period of pregnancy. Several times 
during the examination I felt the uterus contract under my 



53 

hands, and, naturally, it was impossible for me to perceive the 
least foetal resistance, the mole not being embryonic. I was 
also unable to find the rounded prominences, the deep or super- 
ficial furrows pointed out by the authors. I merely found the 
resistance of the doughy mass and nothing else. 

To recognize the coincidence of these two conditions, viz., 
the development of the uterine cavity containing a jelly-like 
mass or a liquid, and the entire absence of all solid parts, is 
exceedingly important, and, in a number of cases, will, alone, 
direct the physician upon the way to the diagnosis. 




PART II. 

THE MEANS TO FIX AND ENGAGE THE FCETAL HEAD DUR- 
ING THE LATTER PERIOD OF GESTATION, AND THE 
DEFINITE TRANSFORMATION OF THE PRESENTATIONS OF 
THE SHOULDER AND OF THE BREECH INTO PRESENTA- 
TIONS OF THE VERTEX DURING THE SAME PERIOD. 

In view of the dangers that surround the child during labor 
when it presents by its pelvic extremity, and the grave acci- 
dents both to mother and child in presentations of the shoulder, 
there is not a practitioner who does not dread to meet such 
cases. 

Therefore obstetricians have already for a long time sought 
to diminish the mortality in these cases, either by a never 
ceasing endeavor to perfect those operations which are resorted 
to under such circumstances, or by trying to find some prophy- 
lactic treatment ; herein recognizing with Wigand that " the 
very ideal of every science and of every art, the very goal of 
all our efforts should be to render such operations useless ; that 
true obstetrics should not only be occupied with the means and 
proper methods of correcting an abnormal fcetal situation, but 
that she should go a step farther, and endeavor to render such 
abnormal situations impossible." 

To effect the total disappearance of these presentations, has» 
indeed, been the dream and the goal of all eminent accouch- 
eurs. And I am happy to say, and loudly proclaim, that a 
number of women and children owe their lives to the means 
extolled by these authors, which means, although imperfect, 
have nevertheless often been employed with success. Observ- 
ing how nature herself sometimes corrects one of these errors, 
obstetricians have sought to imitate her ; and it is thus that 
version by external manipulations has been introduced. Having 



55 

noticed what happened in those cases of so-called sponta- 
neous version, Wigand applied himself to the attentive study 
of these extraordinary changes, and observed, that the simple 
lateral decubitus of the woman, the pressure which she makes 
upon her abdomen during labor, to sustain and bear up against 
it, a single or several efforts at coughing or sneezing, or other 
similar actions, has had a very great influence upon the pre- 
sentation of the child. <( What I have so often seen occur spon- 
taneously," said he, " I shall try to produce myself." 

1 hat beautiful operation, version by external manipulation, 
was made, then modified and finally perfected ! 

A remarkable man, whose recent decease science deeply 
laments, Hubert de Louvain, without knowing the labors of 
Wigand, arrived at the same result forty years subsequently ; he 
recognized the same operation, facilitated its procedure and 
rendered its application more frequent. Wigand and Hubert 
had applied external version only to cases of shoulder presen- 
tation; Mattel, of France, ([856), was the first to announce the 
possibility of transforming breech into vertex presentations, 
and the theory was immediately applied with practical success. 
I certainly try to render justice to all, as is shown in the chap- 
ter devoted to the history of this subject, but I first cite these 
three names, because they truly deserve to be separated from 
a large number of their imitators, for they not only perfected 
the operation, but really made it. It might be thought, that 
after this epoch, version by external manipulation, on account 
of the success accredited to it from the very beginning of this 
century, had now become popular with the profession, but this 
would be quite erroneous. 

It is still very little employed, even up to the present day, 
and when in the medical world one speaks of version, it is 
podalic version by internal manipulation that immediately arises 
in the mind of the practitioner. At first this might seem 
strange, but, upon reflection, it becomes readily explicable. 

To wit, following Wigand, obstetricians have sought far more 
to imitate nature by correcting a bad presentation at the 
moment of labor, than by using the means then normally em- 
ployed by nature herself, i. e. } means to produce a vertex pre- 
sentation. Thus do the following lines, so just and true, from 



56 

the pen of a man whose genius has always been so extensively 
devoted to the progress of science, thus do these lines, I say, 
which seem to impress upon us the uselessness of version by 
external manipulation, and bring to bear against it a judgment 
without appeal, force us to give the true reason why it has been 
abandoned, or practiced merely at hap-hazard. " During ges- 
tation, when the uterine contractions are feeble, and when the 
uterine walls can be easily depressed, one may readily change 
an unfavorable presentation by pressure exerted over the fcetal 
parts ; but these manoeuvres are inadequate to maintain the new 
presentatio?i. To effect this result, it becomes necessary, as 
Wigand has said, to employ other forces, which for the most 
part are not in the power of the accoucheur, but depend entirely 
upon the uterus. This organ, in contracting upon itself, clasps 
the foetus in such a manner as to immediately modify its posi- 
tion and hinder it from reassuming its former attitude. But in 
the absence of these contractions, or when they are irregular 
and spasmodic, it is true, one may still by the aid of external 
manipulation, cause the child in utero to take any position he 
may desire, it will, however, resume its unfavorable position as 
soon as these manipulations cease." v i.) 

In a word, then, accoucheurs have recognized that version by 
external manipulation is possible, indeed easy, but for the most 
part inefficient during gestation and that during labor it is often 
difficult, sometimes impossible, and nearly always dangerous. 
And so, version by external manipulation remained in this un- 
favorable light. Finally, on account of another reason, the 
indications for this operation became extremely rare ; I allude 
to the imperfect knowledge of palpation, the only means of 
physical exploration which can really instruct the accoucheur 
prior to labor, whenever auscultation and vaginal touch give no 
exact information of the situation of the foetus in the uterine 
cavity. 

To-day version by external manipulation should depart from 
this unfavorable prejudice pointed out above, for it can render 
efficient service during gestation, the very time when the most 
favorable conditions for its performance exist. 

1. Tarnier. "Atlas complementaire de tous les traites d'accouchements." 
Paris, 1862. 



57 

r Secondly — Its application should become relatively frequent 
and moreover it should be employed whenever indicated, for 
now, thanks to palpation, we know exactly the attitude of the 
fcetus a long while before the inception of labor. 

In the following chapters I shall study version by external 
manipulation, with regard to its history, its method of perform- 
ance, its indications, and contra-indications, and finally the 
means to be used to render it efficient during gestation. 



HISTORY OF VERSION BY EXTERNAL MANCEUVRES. (i) 

. Suspected by Hippocrates, conceived by Jacob Ruff (Opera 
de conceptu et generatione Jacobi Ruffi. Francofurti adMaenum, 
1580), and Mercurius Scipio (La commare o raccoglitrice, 
1604), the discovery of version by external manoeuvres, as has 
been justly said by M. Nivert, belongs by right to Wigand, the 
accoucheur of Hamburg. 

Wigand, having observed several cases of spontaneous ver- 
sion, undertook to produce for himself what he had seen occur 
spontaneously. " I have not applied myself," says he (2) 
"solely to the modification of the presentation of the child by 
position of the woman during labor, but also by gradual ex- 
ternal pressure over the abdomen and uterus, 

A number of credible observations and researches instituted 
for this object had already enabled me to demonstrate the in- 
fluence of the position of the woman on the presentation o£ the 
child. 

I had still some doubts as to the results that may attend 
external pressure over the abdomen alone. On several occa- 
sions had they appeared to prove efficacious and useful. I 
remembered cases of version by the ordinary method in which 

1. For the entire history of this subject I have made a number of extracts 
from the remarkable works of Nivert : "De la valeur du palper abdomi- 
nal," memoir crowned by the Central Society of Medicine of the depart- 
ment of the North, Lille, 1866. 

2. De la Version par Manoeuvres extemes, by Wigand, translated by Prof. 
Hergott, Strassburg, 1857, p. 5. 



58 

1 had recourse to the introduction of the hand in utero, and 
aided this hand within, by pressure exerted over the abdomen, 
where these manoeuvres had decidedly hastened the success 
of the operation." 

The possibility as well as the harmlessness of changing the 
child's position by external manoeuvres having appeared to him 
sufficiently demostrated, Wigand then studied : 

" i°. — What are the cases and the conditions in which and 
for which a change of the presentation of the foetus, by means 
of simple pressure or other external manoeuvres are possible 
and should be advised ? 

2°. — In these cases, how should the external manoeuvres be 
made, by what means should they be aided, and at what time 
should they be employed ? " 

Necessary conditions for practicing version by external manoeu- 
vres according to Wigand. 

" The first essential is that the waters be not yet evacuated, 
or if that has already occurred that it be but a little while be- 
fore the operation, and be not complete. 

" A second very important condition for the possibility and 
practicability of external version is the persistence of the pains 
or uterine contractions which should be neither too feeble, 
irregular ; or spasmodic. 

u The other conditions in which version by external manoeu- 
vres should be undertaken only with great prudence, are : 
Hemorrhages from the genital organs, convulsions, or repeated 
syncope, persistent vomiting, rupture of the uterus or vagina, 
rheumatic pains, or inflammation of the uterus, premature 
placental separation, &c, &c. 

" Contra- Indications from the foetus. — The first contra-in- 
dication of version by external manoeuvres is prolapse of the 
funis. 

" The second, twin pregnancy. 

" The third, convulsions of the child, hydrocephalus, ascites ; 
cases, which without version, always, or at least ordinarily, de- 
mand the prompt intervention of art. 

Indications. — All abnormal presentations not requiring ac- 
couchement force. 



59 

" Rules and general directions : 

i°. — " Before all, we must seek by every possible means, by 
internal as well as external exploration, to obtain an exact idea 
of the presentation and position of the fcetus in utero. 

2°. — " We should place the woman on that side correspond- 
ing to the pole of the fcetus we wish to engage in the brim. 

3°. — " Being accurately informed of the abnormal position 
of the fcetus, we should make that part nearest to the superior 
strait descend to the pelvic brim. 

4°. — '* By external manoeuvres we should try to direct towards 
the uterine orifice that part of the child which should pre- 
sent. 

5°. — w As soon as we perceive, by vaginal touch, that the 
descent of the head or breech over the uterine orifice has been 
already effected, we should then rupture the membranes in 
order to fix the child in this better position by the compression 
which the uterine walls exert upon it. 

6°. — " When the waters have escaped, not only should the 
woman remain quiet and immovable, and maintain the same 
decubitus, but the abdominal walls should be compressed upon 
both sides, strongly enough, and long enough for the present- 
ing part to sink so deep intothe excavation, that it will hence- 
forth be impossible for the foetus to resume its primitive 
position." 

Wigand then studied the particular manoeuvres in each 
individual case, and ended by showing the advantages of the 
new method over the old. 

From the above, we see that the rules which should guide 
the accoucheur are distinctly formulated, and the principles 
determinately laid down. 

Therefore, it is not surprising to read in the preface to the 
translation, by Dr. Hergott, the following lines from the dean 
of the faculty of Nancy : 

" This book contains more truth, and more useful and prac- 
tical precepts, than are usually found in books of twice the 
number of pages." 

In Germany, accoucheurs, well appreciating the impor- 
tance of this operation, place it in the domain of practice, and 
devote special chapters to it in their dogmatic treatises. See 



6o 

D'Outrepont (i), Ritgen (2), Seibold (3), Busch (4), Kilian 
(5), Rosshirt (6), Lumpe (7), Hilter (8), Grenzer (9), Scan- 
zoni (10), Lange (11), Crede (12), Weissbrod (13), Kohl (14), 
C. Braun (15), Spaeth (16), G. Braun (17). 

The cases in which this operation has been practiced suc- 
cessfully increase and multiply as is shown in the observations 
published by D'Outrepont, E. Michaelis of Kiel (18), and Ed. 
Martin (19). 

Before giving an accurate idea of the opinion of German 
accoucheurs upon this operation, I cannot do better than quote 
the following lines extracted from Schrceder's Manual of Ob- 
stetrics (20), which will convey an exact appreciation of the 
modifications to the rules advised by Wigand : 

" Cephalic Version. — Cephalic version should be performed 
only to improve a presentation, but never to favor extraction, 
because the head remaining above the superior strait, is not 

1. D'Outrepont. Abhandlungen und Beitrage, T. I. Hamberg and Wurz- 
burg. 1822 ; p. 138-147. 

2. FercL Aug. V. Ritgen. Anzeigen der mechanischen Sulfen bei Entbin- 
dungen, Giessen, 1820, p. 411. 

3. Ed. v. Siebold. Lehrbuch der prakt. Entbindungskunde, Nuremburg, 
1821, I 339. 

4. D. W. Busch. Geburtsh. Abhandl. Marburg, 1826, p. 42. 

5. Fried. Kilian. Operationslehrefur Geburtsh., Bonn, 1834. 

6. Eng. Rosshirt. Die -geburtsh. Operat. Erlangen, 1842. 

7. Ed. Lumpe. Cursus der pract. Geburtsh. *Wien, 1843, p. 75. 

8. Huter, Encyclopddisches Worterbuch der mediz. Wissenschaften. Berlin, 
1847, t. xxxvi., p. 80-285. 

9. Naegele's Lehrb. der Geburtsh. von W. C. Grenzer, Mayence, 1854. 

10. Scanzoni. Lehrb. der GeburtsX 3d Ed. Wein, 1855, p. 740-747. 

11. Lange. Lehrbuch der Geburtsh. f. iZe&.,.1851. 

12. Crede. Kiinische Vortrag, iib. Geb., 1853. 

13. Weissbrod Leitfaden der geb. Klin., 1851. 

14. Kohl Lehrbuch der Geburtsh, 1855. Leipzig, 1872. 

15. C. Braun Lehrbuch der Geburtsh. Wien, 1857. 

16. Spaeth, J., Compendium d. Geburt.f. Studirende, Erlangen, 1857. 

17. G. Braun Compendium der Operat. Wein, 1761. 

18. Kleinert Allgemeines Bepertorium. Leipzig, 1838, p. 64 and 65. 

19. Ed. Martin Beitrage zur Gynaecologie. 2. Heft. Jena, 1849. 

20. Carl Schroeder. Minucl d'accouchements, translated by Dr. A. Char- 
pentier. Paris, 1876, p. 296. 



6i 

adapted to an immediate extraction. We should, then, fix precise 
limits to the performance of cephalic version, and should never 
practice it under a?iy circumstances requiring immediate delivery, 

" Moreover there are a great number of contra-indications of 
which only one, supposing the foetus to be alive, merits any 
special consideration. This is the prolapse of the funis. Should 
the cord become prolapsed when the os is only a little dilated, 
it is better not to disturb either the child or the cord, for owing 
to the lateral inclination of the head, the cord is not compressed 
at all. But if the os is sufficiently dilated, we should choose the 
immediate termination of the labor by podalic version, in 
preference to the replacement of the cord and cephalic version. 
All the other contra-indications taken collectively, as many 
accoucheurs admit, have no value whatever. 

" Generally, pelvic contractions would seem to render 
cephalic version impossible, yet very often at the beginning of 
labor, if the degree of contraction is only slight, it may be em- 
ployed with advantage. 

\i the head is near the brim, it is of course an advantage, 
but it is by no means an indispensable necessity. 

The integrity of the membranes facilitate the operation, but 
their rupture does not render it impossible. It is by no means 
really necessary that the pains be regular, especially when 
the os is but slightly dilated; indeed, if there are no pains, 
cephalic version is easy to perform, and the mere prolongation 
of the labor, after a vertex presentation has once been pro- 
duced, is entirely harmless. 

We should decidedly reject the idea that there is any need 
of complete dilatation of the os. As we have said, it is precisely 
when the os is but slightly dilated, that this operation may give 
results particularly advantageous. 

" When we consider the indications for cephalic version, we 
should make a distinction between the different stages of labor. 

' Mattel (i), GEsterle (2), G. Braun (3), Hecker (4), Hegar (5), 

1. Gaz. de Paris, 1855, No. 2. 

2. Schmidt's, Jahrb , Vol. CIV, p. 76. 

3. Ally., Wiener med. Zeit., 1862, No. 65. 

4. Klinik, der Geb., II, p. 141. 

5. Loc cit. 



62 

have already recommended cephalic version during gestation. 

" We may certainly accept this precept in the case where 
there has been occasion to practice touch during gestation, and 
that still more so, when the transformation of the presentation 
generally succeeds without difficulty. Nevertheless, here we 
should not expect to derive great advantage from cephalic 
version, for precisely in the case where at the end of gestation 
the head does not present, the presentation of the child is usually 
of great variability, and consequently the vertex presentation 
which we have produced, has little chance of being maintained. 

" Cephalic version deserves especial consideration at the 
beginning of labor. If the os is still closed, or if it is at most 
passable for one or two fingers, except in certain cases, cephalic 
version should be preferred to podalic And even when the 
pelvis is moderately contracted, it is not contra-indicated under 
such circumstances, because the head has still time enough to 
accommodate itself to the superior strait. It is only in the case 
of placenta praevia we should always prefer podalic version, 
because as the os is but slightly dilated the inferior extremities 
form a better tampon than the head. 

" Both Mattel and Hegar have proposed to transform breech 
into vertex presentations, either during the latter period of 
gestation or at the beginning of labor. In general, the latter is 
more favorable for the child than the former, and as it is sup- 
posed that the transformation may be effected without great 
difficulty, we can have no serious objection to the method." 

In Belgium (1843) Prof. Hubert de Lou vain published a 
notable work upon the possibility of correcting abnormal pre- 
sentations of the foetus by external manoeuvres. (1). 

In reading this excellent memoir, one is soon convinced of 
the fact, that without knowing the works of Wigand, Hubert, 
by conceiving this operation, and by giving for it rules that 
were already so precise and simple, must have understood the 

1. Some clinical facts followed these reflections upon mat-presentation of the 
foetus, and the possibility of correcting them by external manipulations. 

See Annates de Gywxcologie et de Pediatrique, Aug., 1843, p. 381, also 
Encyclographie des sciences medicales. July and Aug., 1843, and the reply 
by M. Hubert to M. Handricke ( Annnles de la society des sciences medicales 
et naturelles de Malines, 1844. T. iii. p. 34). 



63 

accommodation of the foetus during its intra-uterine life, better 
than all his predecessors, and at the same time must have 
thoroughly familiarized himself with external exploration. The 
following is a resume of the teaching of the professor of 
Lou vain upon this subject. ( i) 

" i°. — External version should be performed preferably be- 
fore the beginning of labor. If labor exist, it should be 
performed as early as possible. The contra-indications are 
few. 

2°. — It may be successful, regardless of the amount of liquor 
amnii retained, and indeed even after the entire escape of the 
waters. 

3°. — We should push towards to the pelvic brim that pole of 
the foetus which is least distant. 

4°. — For a successful result it is absolutely necessary (a) to 
have the abdominal walls in a state of most complete relaxation, 
the woman lying upon her back with the thorax and hips a 
little elevated, (£) to operate during the interval between the 
pains. 

" Method of Operating : 

" Place the woman in the dorsal decubitus, the thighs being 
flexed upon the pelvis and the thorax slightly elevated 

" Supposing a shoulder presentation exists, the head being 
in the left iliac fossa, and the breech in the opposite flank, then 
operate as follows : 

Stand to the right of the woman, about the region of her 
thighs, and choosing the moment when tha uterus is thoroughly 
relaxed, apply the two hands above and outside of the cephalic 
tumor and catch this latter between the finger tips. 

Pressing the hand down deep in order to prevent the head 
from sinking behind it, the head is by gentle and gradual 
pressure brought towards the centre of the superior strait, 
while at the same time the breech is assisted in going back to 
the fundus uteri. 



1. The passage which follows is taken from the treatise on obstetrics by 
M. Hubert, Jr., who had the kindness to lend it to me, together with the 
works of his father, which I could not procure in France. For this I ex- 
tend my sincerest thanks. 



64 

K a uterine contraction should come on, wait until it passes 
off, while the hands are merely held in place in order to preserve 
the effect obtained." 

Certainly this teaching is not copied from Wigand, nor is it 
opposed to him as Hubert's son declares. Hubert, the elder, 
has published a certain number of observations, in which this 
method has been practically applied and followed by suc- 
cess. 

" Whenever," says he, " version is performed before labor or 
at its commencement, in order to prevent the reproduction of 
the evil, we must have recourse to other means : 

" i°. — The accoucheur, or an assistant should hold his hands 
in place during several pains. 

" 2°. — He should recommend the woman to lie upon her left 
side, if the extremity of the foetal ovoid which he has turned 
towards the epigastrium, was at first inclined to the right side, 
and vice versa. 

"3°. —Before the operation is performed, a suitable binder 
should be arranged to pass around the flanks of the woman in 
order to follow up the action of the hands. 

" A cushion about the size of the fist should be applied over 
the iliac region, a little to the outside of the point where the 
head or the breech was first found, and a large compress thicker 
above, should be placed on the other side lengthwise with the 
uterus ; then the ends of the binder passing around the body 
under the flanks should be brought together and strongly tied, 
and if so desired the knot may be placed just over the cush- 
ion. 

"4 . — The progress of the labor should be attentively 
watched, and the accoucheur should frequently assure himself 
that the mal-presentation does not return ; if a tendency to such 
recurrence should be observed, it should be prevented by the 
assistance of the hands, by the rupture of the membranes, or 
by the use of ergot." 

In England, even if version by external manoeuvres has been 
so completely abandoned by obstetricians of the first half of 
this century, it is to-day looked upon as having become 
classic. 

As proof of this I need only give what Barnes has said in 



65 

his excellent work on Obstetrical Operations (i), where, after 
having very judiciously shown the connection of external ver- 
sion, after Wigand, with the bi-polar or bi-manual method of 
Braxton Hicks, he gives the indications for cephalic version 
both before and during labor. 

He, like CEsterle, (2) describes the operation during gestation* 
and adds : " When one has produced the desired position, it is 
then necessary to maintain it ; a binder properly applied will 
serve that purpose very well. Lazzati operates after this 
method ; he maintains the position by cushions or pads, which 
he fixes over the two extremities of the fcetal ovoid. 

In America, the observations of Barker (3^, and Taylor (4.^, 
show that the operation is common and is employed with equal 
success by American obstetricians. 

In France, it is not until 1829 that we find in the first edition of 
the " Traite elementaire de l'art des accouchements " by Vel- 
peau, the method of Wigand described in the following man- 
ner : In speaking of cephalic version, Wigand says it may be 
often performed without carrying the hand into the genital 
organs, also that in pressing over the uterus through the 
abdominal wall, and aiding this still farther by position of the 
woman, we can very often turn the head to the centre of the 
superior strait. 

" Before knowing the doctrine of the German professor I had 
already followed this precept, and I have recognized that in. 
complying with it we are sometimes enabled to restore a vertex 
presentation to its natural position ; I have employed it on two 
occasions since with success, before the rupture of the mem- 
branes, but I do not think that this manoeuvre can ever be of 
much avail when the waters have been evacuated for a long 
time and the uterus strongly contracted.'' 

P. Dubois (5) devotes to the operation an important passage 



1. Robert Barnes. Lessons on Obstetrical Operations and the Treatment 
of Hemorrhage. 

2. Sul 1 ivolgimento esterno. In Annali universali di med., 1859. 

3. Barker. Amer. Med. Times, July, 1860. 

4. Taylor. Amer. Med. Times, Dec. 1861. 

5. Dubois, Version Cephalique {in Dictionnaire 30), 



66 

in his article on version, but these lines are far from carrying 
conviction. Dubois, with his great practical sense, was well 
aware of the advantages that might be derived from the opera- 
tion, but having been but little acquainted with palpation, he 
appreciated only the very rare indications. 

In October, 1836, M. Lecorche Colombe, says Belin (1), 
chief of the faculty clinic of Paris, performed in the presence 
of M. Meniere, then serving under Prof. Dubois, a version by 
external manoeuvres for a presentation of the breech. The 
operation having been entirely successful, M. Colombe had 
occasion to repeat it several times, and he presented a memoir 
upon the subject before the Academy of Medicine in 1841, and 
afterwards at the Institute in 1855, which accorded him a 
recompense. (2). 

In 1837, Vulfranc Gerdy (3) in his inaugural thesis, makes 
the following proposition : 

" The external manipulations which are less painful and less 
harmful than the internal, are too little employed to modify the 
fcetal-presentations. Prior to the evacuation of the waters they 
can, aided by suitable position of the woman, promote the 
natural tendency of redressing the foetus, and even after the 
escape of the waters, they may still, at times, suffice when the 
foetus retains sufficient mobility." 

Chailly-Honore, having on one occasion, with M. Devillers, 
performed version by external manoeuvres, devoted to it a 
paragraph in his treatise. (4). 

M. Jacquemier (5), recognizing thoroughly that pressure 
over the abdominal wall could favorably change the situation 
of the foetus, thought that although it should not be entirely 
neglected, it would generally result fruitlessly. In 1855 first 
appeared in the Gazette Medicale, (July No.) some fragments 
of M. Mattel's book, and a few months later the entire work. (6) 

1. Belin, loco citato. 

2. I have not been able to procure this work. 

3. JRecherches et propositions oVanatomie, de pathologie, de toxicologic. Thesis 
No. 128, 1837. 

4. Chailly-Honore. Traite des accouchements. 1842. 

5. Manuel d'accouchements. 

6. Mattel', loco citato. 



67 

In this book, of which I have already spoken in connection 
with palpation, M. Mattel not only shows himself to be an ad- 
vocate of version by external manipulation, but also, departing 
from the usual custom, he affirms a new indication for the opera- 
tion, by demonstrating that it can be used with the object of trans- 
forming presentations of the breech into presentations of the 
vertex. It is, indeed, only in this case, that he cal s the opera- 
tion cephalic version ; in shoulder presentations, which he calls 
indirect presentations, he does not admit the operation, and he 
gives the name of reduction to the operation which has for its 
object the turning of the head into the superior strait. 

The importance of the chapter devoted to the operation by 
M. Mattel', obliges me to quote the principal passages. 

" Cephalic Version. — 

" We consider cephalic version to be the changing of a pre- 
sentation of the breech into a presentation of the vertex. 

" We have observed it to occur spontaneously, but this is rare, 
especially at the end o( gestation, at least when it does not 
coincide with a combination of circumstances altogether pecu- 
liar, of which we shall have occasion to speak hereafter. What 
nature herself did, accoucheurs tried to repeat, and the idea of 
cephalic version in presentations of the breech suggested itself 
to some of them but found many opponents: The difficulty of 
an exact diagnosis, the difficulty of the operation, the few ad- 
vantages that it offered, merely in removing a presentation of 
the b: eech, which is already a natural presentation, and even 
the dangers that were attributed to it in preference to pelvic 
version, in cases of contracted pelvis ; all these reasons and 
others similar, so lessened its value, that it was scarcely at all 
advised by accoucheurs in breech presentations. It is, indeed, 
not yet proven to us that it was practiced before the rupture of 
the membranes, especially on account of the difficulty that was 
experienced in diagnosis. 

'• It was most employed in trunk and face presentations, where, 
as we have seen, it does not deserve the name of version, and 
it was performed especially after the rupture of the membranes. 

" We were not as yet acquainted with the history of cephalic 
version, when a favorable case of breech presentation which 
was recognized before the rupture of the membranes, per- 



63 

mitted us to practice it with the greatest success ; and as this 
operation accorded fully with our ideas, we have since adopted 
it as a general method. 

" To-day we can connect these facts with principles, and we 
do not hesitate to say that cephalic version will not be slow in 
largely asserting its claims over pelvic version. 

" There is one condition that we have regarded as necessary 
both for palpation and version : That is the suppleness and 
slight sensibility of the utero-abdominal walls. This has already 
forced us to appreciate that version is but rarely possible during 
the contractions of labor, or in cases of abnormal tension of 
the utero-abdominal walls, and proves the necessity of examin- 
ing the woman during gestation. 

" Another condition is, that the foetus in the amniotic sac pre- 
serves a sufficient mobility to permit version without inflicting 
violence on the child or mother, and this condition indicates a 
priori the time when version should be practiced : It is the 
period intervening between the sixth month and the middle of 
the ninth. During the last month especially, the foetus acquires 
adipose tissue, and the liquor amnii, if it does not then 
diminish in volume, does not increase in the same proportion 
as it did during the other periods of pregnancy. 

" Another condition which is the consequence of the preceding, 
is, that the breech of the child be not already engaged in the 
excavation. When the presentation of the breech is indirect 
and no matter to what part of the large pelvis the feet corres- 
pond, version is possible, even at the time of labor, but it is 
no longer so when the presentation is direct and the breech en- 
gages in the expanded segment of the uterus. The last fifteen 
days of gestation is precisely the mo:t favorable time for this 
expansion, when the breech, being aptly situated, becomes 
difficult to dislodge. 

" Thus, it has occurred to us on one occasion to try to perform 
version eight days after painful contractions had commenced to 
appear, and that even when the membranes were intact. On 
another occasion, it was also impossible to perform it a few days 
before labor. It is therefore evident why we should examine 
the woman and perform version, whenever indicated, during 
the seventh and eighth month, or at the beginning of the ninth. 



6 9 

The earlier we perform the version the easier it is ; the more 
beneficial is it to the woman by relieving her of the ordinary 
troubles of pregnancy, when a presentation of the breech ex- 
ists, and the more useful to the foetus by averting a premature 
delivery, which is sometimes a consequence of these presenta- 
tions. There is only one case which allows of delay, and that 
is where a dropsy of the amnion permits of great mobility of 
the foetus in all directions, and gives the hope of a spontaneous 
version or a dislodgement from the superior strait of the part 
that was engaged. A last condition necessary for version, is 
that there be no obstacles, such as tumors, shortness of the 
cord, &c, which might oppose the manoeuvres, or the move- 
ments which the foetus has to execute. The recurrence of in- 
direct presentations of the vertex after reduction, is as frequent 
as the recurrence of breech presentation after cephalic version 
is rare ; and these recurrences of indirect vertex presentations 
must be again reduced just as they were when they originally 
existed. These recurrences, however, may happen at times 
and the causes are various; the principal are, an excessive 
mobility of the foetus, too little expansion of the inferior uterine 
segm c nt, a marked inclination of the uterus, and especially a 
considerable contraction at the superior strait. When the 
foetus is movable, and a recurrence after the first version takes 
place, it should be turned again or several times if necessary. 
In such a case, it was only after three operations, that the 
foetus could be finally maintained in a direct vertex presentation. 
Here the version was very easy on account of the abundance of 
liquor amnii. 

"In the case of newly repeated recurrences, the foetus should be 
held in position by means of a bandage applied for that purpose, 
of which I shall speak farther on. If, in spite of these means, 
the presentation of the breech returns, which is, however, rare, 
we should avail ourselves of the mobility of the foetus, by per- 
forming version at the commencement of labor, and maintain- 
ing it until the head becomes engaged in the superior strait. 

"if the dilatation of the os is complete, or nearly so, the 
membranes may be ruptured in order to fix the head. 

"If the recurrence of the mal-presentation be due to a strong 
inclination of the uterus, it is evident that it will continue to 



recur, unless this inclination be corrected, which may still be 
effected by the hypogastric bandage. 

In the widening out of the inferior uterine segment, in its 
entirety instead of in part, by the weight which the foetus exerts 
upon it, we can readily understand, that if the head does not 
rest upon the plane of the superior strait, its weight can no 
longer aid this distension. 

What should then be done to favor this distension, is to 
maintain the head over the superior strait by the hypogastric 
bandage. There is only one case that can offer an obstacle, 
and that is the insertion of the placenta near the os. The 
placental mass which will then often become the cause of the 
mal-presentation, will oppose this widening out of the inferior 
uterine segment, although the internal os remain uncovered. 

These are the cases which frequently present hemorrhages 
during labor; but where the pregnancy none the less often 
advances to full -term. 

Finally, the recurrences of mal-presentations which are due 
to a contraction of the superior strait, do not permit of a phys- 
iological labor and consequently cannot be included in our 
subject." 

In the chapter entitled, Attentions to the Mother, M. Mattel' 
gives the following indications for the application of the ban- 
dage. " This bandage, which has been for a long time casually 
advised, without insisting upon it sufficiently, will render im- 
mense service when it is intelligently applied. For instance, 
its application should not be delayed until an excessive degree 
of anteversion or prolapse of the uterus has occurred, or until 
the last month of pregnancy, for then the evil is done ; it may 
also be harmful in such a case by suddenly changing the 
visceral pressure. The bandage should be applied to all 
women of a slightly lymphatic temperament, or where there is 
reason to believe that the state of pregnancy will not be physi- 
ological, and it should here be used from the seventh month. 

" In order that it should be useful, it is not necessary that it 
be painful, it should support and not compress the abdomen 
When pregnancy is well advanced if a faulty inclination of 
the uterus be observed, the bandage should be assisted by 
small pads, to augment the pressure wherever necessary ; but 



7i 

these pads become especially useful in aiding the maintenance 
of a reduction, or cephalic version, which has a tendency to recur. 

"In these latter cases a binder around the body may be sub- 
stituted for the bandage ; but the binder with the pads soon 
becomes uncomfortable, and should not be used except during 
the last days of gestation." (i). 

In 1857, Prof. Herrgott, in translating a part of the memoirs 
of Wigand (2), that had been already translated by Dr. Belin 
(3), renders a true service to obstetric science, for since that 
time we find a chapter devoted to this operation in all our 
classic works. 

In 1858. Dr. Ducellier, of Geneva, wrote a very good thesis 
on version by external manoeuvres. 

In 1862, Dr. Nivert, in his inaugural thesis, after tracing 
out the history of this question, declared himself to. be an advo- 
cate for version by external manoeuvres, and at the end of his 
monograph gave thirteen cases in his personal experience, all 
successful for mother and child. 

In 1866, Dr. Belin published a notable memoir upon version 
by external manoeuvres, followed by three personal observations. 
This memoir was crowned by the society of Medicine of the 
department of the North. 

Thanks to all these works, as also to the lessons of Prof. 
Stoltz, the method of Wigand is to-day thoroughly known. 

Is it also popular? Is it often employed? 

To these questions I must answer in the negative. And the 
reason that this appears paradoxical is, as well shown in the 
chapter which Cazeaux (4) devotes to version by external ma- 
noeuvres, as in the one by Farmer upon the same operation, in 
his " Atlas complementaire de tous les traites d'accouchements" 
from which I have already given an extract above, viz : the 
inefficiency of the operation during gestation, its difficulty 
during labor, and, I may add, the insufficient knowledge of 
palpation. 

1. Mattei', p. 207-208. 

2. This memoir which had been sent to the' Academy by Wigand him- 
self, received no praise and remained completely ignored, 

3. Belin. Thesis in Strasburg, 1856. 

4. Cazeau, revised by Tarnier, p. 952, 8th Edn. 



72 



METHOD OF OPERATING. 



Before performing the operation, it is necessary that the 
woman be placed in the correct position, i. e., in the horizontal 
dorsal decubitus, with the lower extremities extended end 
slightly separated, the arms lying alongside the body, &c, just 
as when we intend to palpate. 




Fig. 26. — Position of the hands, and direction of the pressure to conduct 

the head by external manoeuvres above the plane of the superior 

strait, in presentation of the shoulder. 



Should uterine contraction occur during the operation, we 
must cease all pressure and wait for complete relaxation. 

Only two conditions may offer : 

i°. — The head may rest in one of the iliac fossae, and the 
breech be in the opposite flank. 



73 

2°. — The head may be in relation with the superior uterine 
segment, while the breech remains below. 

When the presentation is really transverse, as is shown in 
figs. 24 and 25, the operative procedure is essentially the same 
as that employed in presentation of the breech. 

The head in one of the iliac fosses, and the breech in the 
opposite flank. 

In this case apply one hand over the fcetal head, the other over 
the breech, and by gentle and sustained pressure exerted in- 
versely over one and the other extremity, turn the two poles of 
the foetus under the median line. {See fig. 26?) 

This manoeuvre is the simplest, and I have never seen it fail 
during gestation. M. Nivert advises that only the cephalic ex- 
tremity 'be pressed upon, thinking that if the pressure be 
directed inversely, it hinders rather than aids the operation. I 
am not of this opinion, however ; on the contrary, I am con- 
vinced : i°. That the pressures exerted inversely do not at all 
oppose one another. 2°. That the pressure made over the 
breech is more efficient than that made over the head, in as 
much as it is more directly transmitted to the trunk. 3 . That 
in certain cases where the child is large, or the uterus is mal- 
formed and has its long axis transverse or oblique, simple ceph- 
alic pressure may be insufficient, as I have several times 
observed with M. Tarnier. 

Head in relation with the superior uterine segment, breech 
below. 

Here, the first stage of the operation consists in rendering the 
foetus movable. In multiparous women, this is generally easy, 
the two extremities of the child being as a rule accessible, and 
the laxity of the anterior abdominal wall permitting the foetus 
to move in its entirety. 

In primiparae, especially those approaching full -term, when 
the presentation is the result of a true accommodation, the two 
extremities of the child being hidden away, can only be very 
imperfectly grasped by the hands of the operator. 

Sometimes the head is more or less deeply situated under the 
false ribs, in which case a mass of intestines may be interposed 
between the abdominal wall and the uterus. We should then 
try to displace the head, either by pressing it down upon one 



74 

side, or by displacing the breech, and the movements imparted 
to the child have nearly always resulted in rendering the head 
more superficial, and at the same time more accessible. At 
times the head is prehensible, but the pelvic extremity, although 
not engaged, presenting itself perpendicularly to the superior 
strait, slightly presses into the excavation. 

This is especially observed in the incomplete variety of 
breech presentations. 




Fig. 27 — Position of the hands and direction of the pressure, in cephalic 
version by external manoeuvres, the breech being below. 



In order to render the pelvic extremity accessible, and at the 
same time the foetal evolution possible, we should then grad- 
ually elevate this extremity by introducing the finger into the 
vagina and pushing up the inferior uterine segment above the 



75 

brim, when we direct the breech towards one of the sides of 
the large pelvis. This stage of the operation is neither difficult 
for the operator, painful for the woman, nor dangerous for the 
child. 

To facilitate this displacement of the breech, we may at the 
same time exert slight pressure in an opposite direction over 
the cephalic extremity, thereby imitating the operative pro- 
cedure of bi-polar version. The two fcetal extremities being 
movable and accessible, and the hands being applied over them, 
we should make slow and continued pressure in such a manner 
as to cause the breech to ascend and the head to descend by the 
shortest route, (see Fig. 27.) 

Some authors have advised that the pressure should always 
be made in the direction of flexion ; although we may succeed 
with this method in the majority of cases, it is none the less 
true that in some others we must act otherwise. 

I may state that I have never seen extension of the cephalic 
extremity produced. It would perhaps not be so, if we pressed 
upon the cephalic extremity only. 

I repeat that the pressure made over the pelvic extremity, 
has, in every case seemed to me to be more efficient than that 
made over the cephalic extremity. 

Let it be well understood, that if, after several endeavors, the 
evolution of the foetus shows no tendency to be produced, we 
should desist, as I have already shown in the chapter on contra- 
indications. 

It should also be remembered that, although the operation is 
easy and rapid in multipara?, we may find it more difficult in 
primiparae. With them the pressure should be more sustained, 
more prolonged, and even then we may not succeed in all 
cases, although we may have taken every precaution to avoid 
interference from the involuntary contractions of the abdominal 
muscles. 

During the past year, at the Maternity, M. Tarnier, having 
diagnosed a presentation of the breech upon a woman about 
8^2 months pregnant, lying in St. Adelaide's ward, tried in vain 
to perform version by external manoeuvres. Having myself 
attempted the same, I was no more fortunate. The abdominal 
wall of this woman was very thick and constantly tense. 



7 6 

In order to relax the muscles M. Tarnier finally gave chloro- 
form until they were entirely flaccid, and even in that condition 
neither one of us could turn the child. Certainly, in this case, 
everything was normal, as was determined at the time of 
labor ; it was the tonicity of the abdominal muscles, and per- 
haps also of the uterine wall, which in opposing the increase of 
the transverse diameter of the uterine cavity prevented the 
evolution of the foetus. Perhaps had we operated earlier the 
version would have been possible. 

Thus, as you observe, I have not mentioned either the fric- 
tions recommended by Wigand, or the lateral decubitus of 
Hubert, for these different procedures are always painful to the 
woman, and it is only by chance that they succeed. Although 
by no means do I desire to discuss here, if in certain cases of 
contracted pelvis the presentation of the vertex is not more de- 
sirable than that of the breech, I should, however, say a few 
words concerning pelvic version by external manoeuvres. I 
have performed this operation only once at the Maternity, upon 
a woman about 8 months pregnant, who had a contracted pelvis 
(sacro-pubic diameter at least 8 c. m). 

In this case, of which I give the history below, the head was 
above the superior strait. I operated by placing my two hands 
over the two fcetal extremities respectively, as in cephalic ver- 
sion, and the breech rapidly descended. I believe that there 
are no other rules to follow. 

Contracted Pelvis. — No Presentation. — Cephalic Version by 
External Manoeuvres. — Bandage. — Pelvic Version by Ex- 
ternal Manoeuvres. — Bandage. Induced Premature Labor. 
— Child living. 

(Reported "by Dr. Eibemont.) 

B aet. 35 years. 

First Confinement, July 31, 1875. 

Vertex presentation. Application of the forceps by M. Po- 
laillon. Mechanical traction by the aid of the machine of Pros. 
Child dead. Boy, weighing 3,800 grms. The tractions were 
of more than 40 kilog. power. 

The second pregnancy began in April, 1877. Last menstru- 
ation from April 22d to April 27th. The woman was small and 



77 

had been affected with rachitis about the age of one and a half 
years. At that age she sustained a fracture of the left ihigh. 
The leg was shortened eight centimetres. First menstruated at 
the age of n years, and has been regular ever since, each 
period lasting 5 days. Entered the Maternity Oct. 24. 

Abdomen large, liquor amnii abundant. Above the plane of 
the superior strait we felt a large mass, continuous in the right 
flank with the surface of a resisting plane. Above the umbili- 
cus the fcetal part appeared more regular than that which lay 
nearer the superior strait, it was difficult to map out, and 
moved readily under the hands. The heart- sounds were heard 
on a level with and to the right of the umbilicus, the cervix was 
large and firm, the os externum patulous and very much torn. 
The examining finger easily reached the sacro-vertebral angle 
and also readily touched the anterior face of the sacrum. The 
conjugata interna measured 9 centimetres. 

The patient remained under observation during the month of 
November without the foetus leaving its situation. 

Dec. 8th M. Pinard, by invitation of M. Tarnier, performed 
version by external manoeuvres and readily turned the ceph- 
alic extremity into the superior strait. Bandage applied. On 
the subsequent days we found that the head still remained 
below. 

Dec. 23d the patient loosened her bandage after having re- 
moved the thigh straps. On the following day the head was in 
the right hypochondriac region, breech in the left iliac fossa, 
and the back directed anteriorly and below. Pelvic version by 
external manoeuvres was performed, the breech being turned 
directly over the superior strait and the bandage re -applied. 

Dec. 29th, a. M., the breech not changed. M. Tarnier de- 
termined to induce labor and kept one of his dilators for ten 
hours in the uterus. The first pains appeared at n A. M., and 
continued feeble until 9 p. M. when they became more powerful. 
The woman was removed to the lying-in chamber. Cervix 
effaced. Os dilated 1 j4 c.m. in diameter. 

Presentation of the breech, S. I. R. A. 

Dilatation complete, December 30th, 6:45 A. M. Spon- 
taneous delivery at 7 A. M. Child living. Girl, weighing 
2 >95° gnns. 



78 

INDICATIONS AND TIME OF ELECTION FOR 
THE OPERATION. 

During gestation : In all cases, where, after eight months 
of gestation the head occupies either the iliac fossa or the 
superior uterine segment, we should perform cephalic version 
by external manoeuvres. It is indispensable to well define and 
give reasons for these several indications, if we can. 

Knowing the history of the foetus during its intra- uterine life, 
it results, that if at the eighth month of pregnancy the head 
should not sink, either partly or entirely into the excavation, we 
can affirm that the accommodation is abnormal or incomplete, 
or altogether faulty. We should then correct this by external 
version. 

But you will object, and not without an appearance of reason, 
as follows : 

Do we not often observe evolution to occur spontaneously, 
and the head to present at the superior strait and engage either 
during the last weeks of pregnancy, or indeed at the commence- 
ment of labor ? 

That is perfectly true, but it is none the less true, that spon- 
taneous evolution does not always occur, as is proved by the 
number of mal -presentations. 

Therefore, if after having determined the faulty attitude of the 
foetus at the period above indicated, we do not interfere, we 
leave both the mother and child to their fate. What would be 
said to-day of an accoucheur who, confiding in the resources 
of nature and relying upon the occurrence of spontaneous ver- 
sion, sits passively with folded arms before a woman in labor 
with transverse presentation? Nevertheless a certain number 
of spontaneous versions have been recorded. And should not 
the same opinion be held of him who relies upon the occurrence 
of spontaneous version during the last month of pregnancy ? 

I am well aware that M. Tarnier has written : "In a consid- 
erable number of cases the uterine contractions will suffice to 
rectify the presentation and will bring about a perfectly happy 
labor." But that was at a time when he, with reason, wrote after 
these lines the following : " useless during gestation, impossible 
when the shoulder is deeply engaged, external version, in our 



79 

opinion, is not applicable, save in certain exceptional cases, 
where it does offer incontestable advantages over internal ver- 
sion." But now the opinion of my esteemed teacher has 
changed completely. Knowing how easy it is to render the 
operation efficient during gestation, he no longer hesitates to 
advise it to be performed, even during that period. Moreover, 
he authorized me to publish the following case, in order to show 
how imprudent it is, always to rely upon the resources of nature. 

Presentation of the Left Lateral Plane. — Versio?i by External 
Manoeuvres. — Application of Dr. Pinard's Abdominal Ban- 
dage. — Premature Removal of the Bandage. — Reproduction 
of the Shoulder Presentation. — Podalic Version. 

(Case reported by Dr, Eibemont, interne at the Maternity.) 

Mrs. D., aet. 31 years, vm-para. 

This woman, well formed, menstruated at the age of ten 
years, and since then has been regular every month for eight 
days at a time, profusely. 

Five of her pregnancies were terminated at full-term by 
natural labors ; vertex presenting. Two other pregnancies were 
terminated by abortions the cause of which is not known. 

She entered the Maternity July 10th, St. Adelaide's ward, 
bed No. 2, believing herself to be near full term. 

Her last menstruation was from the iSth to the 24th of Sep- 
tember. 

During the course of her pregnancy she suffered severe ab- 
dominal pains. She had syncopes and gastric disturbances. 

Her abdomen was developed to the size of one at the ninth 
month of pregnancy, although the fundus uteri was uot much 
elevated above the umbilicus. Palpation revealed the pelvic 
excavation empty, but in the right iliac fossa the head was 
found, ballotting freely. In the left flank the other extremity 
of the foetus was perceived. The inferior extremities were not 
distinct 1 y felt. Going from one pole to the other a large resist- 
ing plane was fonnd. - 

The diagnosis was presentation of the left shoulder in the 
right cephalo -iliac position. 



8o 

Auscultation. — Heart sounds perceived under the median line 
at an equal distance between the umbilicus and the pubes. 

Toicch. — Pelvis normal, excavation empty, cervix soft and 
admits one finger, but still has considerable length. 

July 15, M. Tarnier performed version by external manoeuvres, 
the head being turned into the superior strait, and M. Pinard's 
bandage applied to hold the foetus in its new presentation. Dur- 
ing the subsequent days the head did not leave the superior 
pelvic strait, nor did it engage. 

July 29th, M. Tarnier, desiring to see if the head retained its 
situation, removed the bandage, when it resumed its former 
attitude. On the two following days everything remained in 
statu quo. 

July 23, in order to clear out St. Adelaide's ward, the patient 
went up into the dormitory and from that time forth she escaped 
our close observation. 

July 30th, 7 p. m., she entered into labor and was removed to 
the lying-in chamber. The neck w r as effaced and the os dilated 
to about the size of a five franc piece. The transverse presen- 
tation had been reproduced. The left shoulder in the right 
cephalo-iliac position presented. The bag of waters was so 
large we could not touch the foetus. 

At 10 A. m., the dilation being complete, podalic version was 
performed, and quite a large, living, female child delivered. 

Weight 3280 grms. 

Length 4^ cent. 

Diameters of head, O. M 13 " 

Bi. P 9 " 

The woman left the hospital Aug. nth. 

Thus, in this case, can one see that not only were the uterine 
contractions unable to correct the mal-presentations, but even 
external version was completely useless, as soon as the bandage 
was removed. As regards the result of the case, of course we. 
have nothing to regret, as the child was born alive, and the 
mother made a very good recovery, but should we have the 
presumption to say that neither one nor the other was exposed 
to danger ? 

For four years, excepting the instance which I shall cite be- 



8i 

low, I did rot observe but one single case of shoulder presenta- 
tion which was left entirely to nature ; in all the other cases the 
intervention of art was followed by success. 

In brief, this is the instance to which I allude : Feb. 2 th, 
1876, a 11-para, about eight months pregnant, was placed in 
No. 28 of the Clinical hospital. At the examination, palpation 
revealed a shoulder presentation, but by vaginal touch no part 
of the fcetus could be felt. External version was performed, 
the bandage applied and maintained. March 2d, another 
woman beginning to suffer a little, was received into the lying- 
in ward. Being immediately examined, it was found that the 
child offered a breech presentation. I then performed, before 
Prof. Depaul and the students, version by external manoeuvres 
and applied the bandage ; but as at that time the hospital only 
afforded one bandage, I was obliged to take the one applied to 
the woman in bed No. 28, thinking that as she was advanced 
but eight months and a half in her pregnancy, I would have 
time to procure another for her. 

The moment I removed it, the head commenced to rise up 
out of the excavation. That same evening both women were 
in labor in the lying-in chamber, but wh'le the one who had the 
binder, i. e., the one upon whom I had performed cephalic 
version for breech presentation was in the second stage of nor- 
mal labor, vertex presenting, the other had her thighs separated 
and a hand appeared at the vulva, i. e., the original transverse 
presentation had returned. I shall never forget that day, 
marked by two such demonstrative examples, that occurred 
before a considerable number of students ! 

Thus we see that we should not rely too much upon nature. 
It may still be objected that we should watch the woman atten- 
tively during the last months of pregnancy, but interfere only 
during the last days, or indeed not until the very commence- 
ment of labor, if the presentation remains faulty. In fact that 
can be done, but may not the membranes rupture prematurely ? 
Will one always be on hand at the commencement of labor ? 
And finally, who shall declare within a few days the exact age 
of the pregnancy? How many women are confined fifteen 
days, three weeks, or indeed even a month before the appointed 



82 

time ? All accoucheurs are aware of this, and I by no means 
allude solely to premature labors, but also to labors at full-term. 
The last reason which has made me assign t:e eighth month as 
the time of election is because at that time the foetus being in- 
completely developed, it enjoys in most cases a sufficient 
mobility to permit of turning in all directions. 

At a more advanced period of the pregnancy, the evolution 
of the foetus upon its long axis becomes difficult, and some- 
times, indeed, impossible. If shoulder presentations do con- 
stitute a distinct and accepted indication for every one, it is by 
no means the same with the presentations of the breech. 

According to some authors, Prof. Hubert de Louvain among 
others, breech presentations should be considered as normal, 
and consequently we should not attempt to substitute for them 
presentations of the vertex. I am surprised that a man as bold 
as Hubert, and of such large experience, should maintain such 
an opinion ! Especially, when the statistics of Madame Lach- 
apelle show that one child dies out of every ten ; and from the 
statistics taken from the Upper Rhine district, Hegar (i) cites 
the following : 

Mortality for children in breech presentations. 
35 out of ico, still-born. 

5 " " ioo, die on the first day. 
Mortality for children i?i vertex presentations. 

2.4 " " 100, stiil-born. 

1. " " 100, die on the first day. 

Mortality for mothers. Vertex, 0.57 out of 100, die. 
Breech, 1 " " ico, '• 

When Hecker in his book (2) estimates the mortality for 
children in breech presentations as 22 out of 100, how is it pos- 
sible to admit that labor in cases of breech presentation can be 
normal ? Is it natural in mechanism ? yes ; in its results ? no ! 

I can far better understand Velpeau (3) and Maygrier (4) 

1. Hegar, in Deutsche Klinik, No. 33, 1866. 

2. Klinik der Geburtsh., t. 2. 

3. Velpeau, loco citato. T. 1°. article 2, p. 531. 

4. Maygrier. Nouvelles demonstrations d' accouchement. Paris, 1840, p. 301. 



»3 

who describe this presentation in the part of their trestises en- 
titled : Unnatural Eutocia. 

Therefore in view of the prognosis being such, that we find 
nothing similar to it except in the most terrible diseases, I think 
that all efforts to substitute a vertex presentation for a breech 
are legitimate, and will farther say, should be tried in all cases. 
Other authorities have considered cephalic version in cases of 
breech presentations dangerous both for the mother and child, 
or, indeed, even impossible. Thus Scanzoni says (i), "even 
in those very cases where the body of the child possesses suffi- 
cient mobility, it will still be quite difficult to turn the head 
toward the superior strait when it is far removed from it. Thus, 
one of the indispensable conditions for the success of the 
operation, is that the head of the foetus should be near the 
superior strait." And so, the indication distinctly announced 
for the first time by Mattel in 1866, was actively opposed both 
at home and abroad. " Never," exclaimed Martin in the ob- 
stetrical society of Berlin (2), "should any German physician 
dare to perform cephalic version in cases of breech presentations ..' 

Notwithstanding this anathema uttered by the Berlin pro- 
fessor, the idea of cephalic version in breech presentations has 
progressed. Notice how Hegar (3) expresses himself in an 
excellent article upon version by external manoeuvres. " If we 
consider breech presentations to be more unfavorable both for 
the child and the mother, I cannot understand why we should 
not permit such an operation to become an established pro- 
cedure, if it prove to be of no inconvenience to the mother. 
Cephalic version by external manoeuvres in presentations of the 
breech, is perfectly justifiable when no contra indication exists, 
such as contracted pelvis or death of the child. 

" But we cannot definitely judge this operation until a large 
number of observations have been made. Far from recom- 
mending this operation in all cases, a priori, I do not think 
that we should object to its performance, and I believe that the 
results I shall give will elicit new trials." 

1. Scanzoni, translated by Picard p. 301. 

3. Monatsschriftfilr Geburtsk. T. xvi. p. 1. 1860. 

3. Hegar in Deutsche Klinik, n°. 33, 1866. 



8 4 

SHORT OBSERVATIONS REPORTED BY HEGAR. 

i°. Case. H-para, at term. Breech presentation. Com- 
mencement of labor. Neck effaced. One finger introduced in 
the vagina, pushed up the breech, while the other hand forced 
down the head ; the version was easily effected. The woman 
was placed on her back and a cushion applied over the fcetal 
head. Version was performed at I p. m. ; pains were frequent 
at 3 p. m. ; delivery at g p. M. Presentation of the vertex, 
O. I. L A. 

2° Case. Woman 28 years old m-para, former labors nor- 
mal; examined June 5 th. Breech presentation. Version was 
performed by gradual inverse pressure over the head and 
breech, and vaginal touch soon revealed the head below. June 
8th, head in the left flank breech in the right ; transverse pre- 
sentation. The head was again turned below. June 9th, pains 
regular, head to the left above the umbilicus. The assistant 
tried to perform external version but did not succeed at first, 
but sometime after the pains had subsided, version was per- 
formed. Delivered June 10th. Vertex presentation, O. I. L. A. 

3 Case. E. cet. 37 years, m-para. First examined 
May 29th ; abdomen pendulous ; no part of the foetus engaged ; 
head above, breech below. Version easy after two attempts. 
May 30th, head reascended above and to the right; breech just 
over the pubes. A student readily performed external version. 
Repeated examinations on subsequent days, invariably showed 
the head to be at the superior strait. Labor during the night 
of June 26th and 27th, vertex presenting. Child alive. Mother 
did well, as in the other two cases. 

I have thought it best to give these observations because they 
are instructive in every respect. They show . 

i°. — That in breech presentations cephalic version is possible. 

2 . — That it is not dangerous either for the mother or the 
child. 

3 . — That the original presentation may recur, even after 
several versions. 

In reading the observations appended to the end of the 
chapter, one will observe that in all the cases where cephalic 



85 

version was performed for breech presentations there was never 
any trouble either to the mother or the child. All the authors 
consider an abnormal placental insertion to be a contra-indica- 
tion. Far from being of their opinion I consider this accident 
of pregnancy to be a fixed indication (i). 

To-day, when "accouchement force " is justly proscribed, 
one should not think of extracting the foetus until the os is di- 
lated or dilatable. Yet, is podalic version or extraction by the 
feet preferable to the application of the forceps in such a case ? 
I think not. (2) 

I do not know that I may be permitted to record here, certain 
facts relative to this question, but in a case of marginal placen- 
tal insertion that had already caused three severe hemorrhages, 
I performed cephalic version by external manoeuvres, and hav- 
ing forced the foetus to engage, the hemorrhages did not recur 
either during gestation or labor. 

Here is the entire observation as I reported it to the chirur- 
gical society. 

1 1- Para. — Ab?ior??ial Placeyital Insertion. — Presentatioji of the 
Left Shoulder. — A. I. R. — Version. — £a?idage. — Delivery 
by Vertex. O. I. L. A. 

G- set 21 years, florist; entered the hospital Aug. 17th, 
1876, service of Professor Depaul, substituted by M. Gueniot. 
This woman, occupying bed No. 8 furnished the following his- 
tory. 

Dec, '74. First labor ; natural delivery ; child at term ; ver- 
tex presentation, Puerperium normal, menstruation returning 
six weeks after labor (she nursed for nine days only). Cata- 
menia regular until Nov. 25, 1885, then suppressed. This last 

1. In cases of placenta prcevice the translator would decidedly prefer to deal 
with breech presentations. See Article by R. Lamer in Amer. Jour of Obstet- 
rics, Dec. y S4, and nearly all the standard authors. 

2. With all due respect to the authority, the translator still considers internal 
podalic version, when possible, to be preferable to the high forceps operation. See 
article by Kingman in Amer. Jour, of Obstetrics, July, '84, page 723. Also 
Simpson and other standard authors. 



86 

menstrual period was of the same duration as the others, 
although the amount of blood lost seemed to have been less. 
The first six months of this pregnancy progressed favorably. 
Towards the seventh month, July 30th, 1876, at 6 A. m., whilst 
still in bed, she felt wet- She lit a candle and saw that it was 
blood. She thought that she must have lost about half a tum- 
bler-full. A midwife was then consulted, who advised quiet 
and cold drinks. She, however, continued to bleed until the 
evening, when it ceased completely. For fifteen days subse- 
quently, she suffered pains in the flanks and hypogastrium. A 
few days afterward, July 24th, a fresh hemorrhage occurred 
again while she was asleep. She said she then lost more than 
half a litre of blood. At midnight she was brought into the 
clinic. As soon as she was placed in bed, the hemorrhage 
ceased. On the 6th or 7th of August, during her stay in the 
hospital a small, insignificant hemorrhage occurred. She left 
the hospital Aug. 14th, '76. Three days afterward, Aug. 17th, 
the patient, while lying down, began to feel uncomfortable ; she 
got up and flooded the floor with blood. A half hour after- 
wards she arrived at the clinic, where once in bed the hemor- 
rhage again ceased. 

Sept. 9th. Since her entrance she had no more hemorrhages, 
but suffered constantly in the flanks and hypogastrium. She 
gained a little color. The abdomen was well developed and 
presented a cordiform appearance, especially during con- 
tractions, which were frequent. The uterus stood six finger 
breadths above the umbilicus. Palpation showed the excava- 
tion and inferior uterine segment empty. The foetal head was 
situated in the right flank, in relation with the false ribs ; the 
breech was in the left flank nearly upon the same level as 
the head ; the back was in front. It was a transverse presenta- 
tion in the true acceptation of the word. The maximum in- 
tensity of foetal heart sounds was found about the level of 
the umbilicus. Uterine souffle, synchronous with the maternal 
pulse was perceptible, especially to the left of the linea alba ; 
this souffle could be made to disappear by pressing between 
the stethoscope and the anterior iliac spine. 

Touch revealed throughout the entire extent of the vagina 



»7 

arterial pulsations. The very large neck, having its entire 
length, was directed to the left and decidedly posteriorly. No 
foetal parts were accessible ; no difference was perceived between 
the two culs-de-sac ; the inferior uterine segment was quite 
regular. 

Sept. nth. The breech descended and rested in the left 
iliac fossa. We had a breech presentation : S. I. L. A. The 
woman suffered a great deal. 

Sept. 1 2th, p. m. M. Pinard, chief of the clinic, performed 
cephalic version by external manoeuvres, the operation being 
very easy. Upon examining the woman, we found a vertex 
presentation : O. I. R. P. 

Sept. 14th. The position of the foetus had not changed. 
The patient suffered much ; she could sleep but little. 

Sept. 15th. Presentation the same, the position changed into 
O. I. L. A. The head movable over the brim, not engaged. 
M. Pinard applied the bandage. Touch confirmed the signs 
furnished by palpation. In carrying the finger high up behind 
the symphysis pubis the head was felt to be very movable, and 
readily permitting of its being pushed away. 

Sept. 16. Since yesterday, frequent urinations, but no 
pains. 

Sept. 20. The head sunk in the excavation was still, how- 
ever, not immovable. We could readily push it up a little with 
the fingers. The neck was directed posteriorly and to the 
left. We could easily recognize that the anterior half of the 
inferior uterine segment was decidedly thicker than the poste- 
rior. 

Sept- 25th. Since last night she suffered pains about every 
quarter of an hour. Touch showed the vertex deeply engaged. 
Neck effaced ; os dilated to about the size of a 20 sous piece. 
The head could be distinctly felt through the membranes. De- 
livered at at 5:10 p. m., of a boy weighing 3.610 grms. Vertex 
presentation. O. I. L. A. 

During the stages of dilatation and expulsion she did not lose 
one single drop of blood ; but the expulsion of the placenta was 
accompanied by a hemorrhage of about 500 grms. 



88 

Examination of the Placenta. 

The membranes ruptured near the border of the placenta. 
At this place the placenta showed lesions which attested the 
preceding hemorrhages. There was an atrophy and an almost 
complete disappearance of the cotyledons ; in their place was 
quite a thick layer of stratified fibrin of a greyish hue. This 
portion of the placenta which measured 3 centimetres in breadth 
and 1 1 in length contrasted with the rest of the after-birth, by 
its appearance, its color and its thinness. 

Oct. 5th. At her own request she left the hospital. The 
puerperium had been normal. She still presented a decided 
anaemia on account of her abundant hemorrhages." 

In this case did the head by strongly pressing upon the in- 
ferior uterine segment, and at the same time upon the placenta, 
prevent the recurrence of the hemorrhages ? Only having this 
one instance, I cannot affirm this, but in view of such evils as 
frequently do follow the known treatment, I think with Simp- 
son (1), that every attempt to diminish the dreadful mortality 
in these cases is worthy of the attention of obstetricians, even if 
they should not be willing to concede their approbation and 
their conviction. Moreover, I believe that in no case where the 
foetus presents by the breech or the shoulder, should the im- 
plantation of the plancenta over the inferior uterine segment con- 
stitute a contra-indication to version by external manoeuvres. (2) 

CONTRA-INDICATIONS. 

The contra indications for cephalic version by external ma- 
noeuvres are very few, especially when the operation is per- 
formed during gestation. 

There is indeed but one, the source of which is sometimes 
maternal, sometimes foetal, but which generally proceeds from 
both organisms. I allude to the imperfect mobility of the foetus 
hindering version. This condition may be found : 

i°» In cases of multiple pregnancy. — 

One can readily understand that it would be rash and danger- 
ous to think of changing the presentation when the two foetus 

1. Simpson. Obstetrical Clinic. 

2. See note on page 85. 



8 9 

present, the one by the shoulder, the other by the breech. 
The pressure would rupture the membranes if the sacs were 
distended, or alter the relation of the foetal annexes, particularly 
of the umbilical cords. In such cases I do not think we should 
interfere before labor or before the rupture of the membranes, 
but always, be it remembered, during the interval between 
uterine contractions. 

Immediately after the expulsion of the first child, the second 
foetus, be it either in a sac to itself or in one common to both, 
possesses sufficient mobility to permit of its vertex being turned 
below by external manoeuvres, no matter what may have been 
its original presentation. 

The capital point is, to make the diagnosis of the multiple preg- 
nancy, so that, should we find, let us suppose, one head above, 
we would not think of pushing it down by repeated endeavors, 
when at the same time we perceive that the second foetus 
would prevent the version. Nevertheless such manoeuvres may 
sometimes be performed without there resulting any harm 
either to the mother or the child. I know of one case of mul- 
tiple pregnancy, where the accoucheur, thinking he had to do 
with a breech presentation in a simple pregnancy, after efforts 
that were fatiguing to himself, transformed the breech presen- 
tation into one of the vertex. A few days later labor began, 
and he assisted at the birth of two fine children, both of whom 
presented by the vertex. 

2°- In cases of breech presentation in primiparce. 

When the presentation is the result of an accommodation 
and remains the same, i. e., fixed, during the latter period of 
pregnancy, when, in a word, there exists the variety of presen- 
tation which I call frank, version may be impossible. 

We should then cease the manoeuvres after several fruitless 
endeavors, and repeat them after an interval of several hours or 
days, but they should always be practiced with the greatest 
gentleness and slowness. 

I have already had occasion to relate three such cases, one 
of which was seen with M. Tarnier. 

j°. In cases of shoulder presentation where there is a mal- 
formation of the uterus. 

Here again the presentation is the result of an accommoda- 



go 

tion; the uterine cavity being mal-developed, is not very 
spacious, and, indeed, sometimes has a prominent projection 
along the median line of its internal surface, as in the cases 
published by M. Polaillon. 

We can understand that in such cases, the mobility of the 
foetus may be decidedly limited. Also in these cases must we 
be very careful in our manipulations. 

In one of M. Polaillon' s cases, version was impossible, but I 
may add that in a similar case I observed in the service of Prof. 
Broca, I was able, without employing any very great force to 
transform a presentation of the shoulder into a presentation of 
the vertex. 

4°. hi cases where version is performed during labor. 

The mobility of the foetus is lost when the membranes are 
ruptured, for the quantity of liquor amnii retained is insuffi- 
cient to preserve a sufficient dilatation of the uterine cavity, to 
favor the movement, and also because of the subsequent fre- 
quency of uterine contractions. It is just at this time that, 
when operating we may perhaps produce a prolapse of the 
foetal extremities, or of the cord, as also presentations of the 
face, or inclined varieties of the vertex. 

Concerning the other conditions, generally considered by 
authors as contra-indications, I shall merely mention them, in 
order to show their little importance. 

Thus, hydrocephalus, death, deformities, ascites of the foetus 
on the one hand ; hemorrhages, convulsions, syncopes, persis- 
tent vomitings, strangulated herniae, aneurisms of the mother, 
on the other, have been considered as contra-indicating exter- 
nal version. I do not desire to discuss these facts. 

THE MEANS FOR DEFINITELY TRANSFORMING PRESENTATIONS 
OF THE SHOULDER AND OF THE BREECH INTO PRE- 
SENTATIONS OF THE VERTEX. 

History. 

Among those accoucheurs who have given their attention to 
cephalic version by external manoeuvres, and have advised that 
the operation should be performed during gestation, there are 
some, few in number it is true, who think that the newly pro- 



91 

duced presentation is and will remain fixed after the version, 
and consequently without condemning the precautions taken 
for this object, they reject them as being well nigh useless. 

M. Nivert says : " We have performed external version fif- 
teen times, both before and during labor. In only one case 
have we observed the mal-presentation recur, and that was in a 
woman threatened with premature confinement at the seventh 
month of her pregnancy. 

*The foetus was small, movable, and maintained the situation we 
gave it only with difficulty. Hence, we believe, that when we 
have performed this operation during pregnancy and effected 
this alteration in the relation between the child and the uterine 
cavity, that the new presentation will be maintained in the great 
majority of cases ; if, perchance •, it should not be maintai?ied y 
zee should desist from its farther performance, to repeat it when 
labor sets in" (i) 

These lines would astonish those, who have so often observed 
the mal-presentation recur after the performance of version by 
external manoeuvres, if, after a closer study of M. Nivert's 
work, they did not perceive : 

i. — That in only six cases was the operation performed dur- 
ing pregnancy, and even then at a time but little removed from 
the period of labor. 

Twice 2 days before labor. 

Once 3 " 

(i _ << u a 

" Q it " " 

u I2 " " " 

2°. — That in perhaps only one case, No. LX, was the oper- 
ation performed for a breech presentation. 

Although these remarks may detract from the importance of 
M. Nivert's assertions, and although I justly appreciate the 
value of his important work, I cannot agree with his conclu- 
sions, and am convinced that he must have had a particularly 
fortunate series of cases. In fact, the majority of the partisans 
of version by external manoeuvres, have observed the frequency 
of the recurrence of the mal-presentation. The very discoverer 

1. Nivert, loco citato^ p. 75. 



92 

of the operation, Wigand himself, was convinced of this fact 
when he recommended that the operation should not be per- 
formed except at the time of labor, and still farther formulated 
the following precepts : 

i °. — ' ' As soon as vaginal touch shows that the external ma- 
noeuvres have effected the descent of the head or breech over 
the os uteri, we should rupture the membranes, in order to fix the 
child by the compression which the uterine walls exert upon it. 

2°. — At the moment the waters have escaped, not only should 
the woman remain perfectly quiet, but the abdomen should be 
compressed upon both sides quite forcibly and slowly, until the 
presenting part has penetrated so deep into the excavation that 
it will thenceforth be impossible for the foetus to resume its 
primitive position." (i) 

Hubert de Louvain also believed in the recurrence of the 
mal-presentation ; he advised to resort to the following means : 

i°. — "The accoucheur or an assistant should hold the hands 
in position during several pains. 

2°. — He should advise the woman to lie upon the left side, 
if the extremity of the fcetal ovoid which was turned towards 
the epigastrium was originally on the right, and vice versa. 

3°. — A binder passed under the woman's flanks before the 
operation will take the place of the hands." (2) 

Mattel, being of the same opinion, says : " When the foetus 
is movable and there is a recurrence of the mal-presentation 
after the first version, we should turn once more or several 
times. In such a case it was only after having operated three 
times, that the foetus was finally maintained in a direct vertex 
presentation. 

Should there be new recurrences, we should maintain the 
foetus in position by a bandage applied for that purpose. "If 
notwithstanding these means the presentation of the breech 
should recur, which is rare, we should profit by the mobility of 
the foetus, and perform version at the commencement of labor 
and maintain it until the head engages in the superior strait." (3) 

It was after having observed the frequency of the recurrence 

1. Wigand, loco citato. 

2. Hubert, loco citato, on version by external manoeuvres. 

3. Mattei', loco citato, gives two very interesting cases. 



93 

of mal-presentation after version, that M. Tarnier wrote that 
the operation was both inefficient, and, indeed, useless, during 
gestation. 

Schrceder says : " We should not expect to obtain any very 
great advantage from cephalic version when performed during 
gestation, for precisely in those cases where at the end of preg- 
nancy the head does not present, the presentation usually offers 
a great variability, and consequently the cephalic presentation 
which we have produced has but little chance of being main- 
tained." (i) 

We have seen in Hegar's cases quoted above, that this 
author was obliged to perform cephalic version repeatedly in 
the same case in order to maintain the head below. 

Ellinger (of Stuttgart) (2), in a memoir upon version by ex- 
ternal manoeuvres, gives two very interesting cases, which 
demonstrate that although the operation was performed towards 
the end of gestation, as well as at the commencement of labor, 
one operation was far from being sufficient. The following is 
the resume of these two cases : 

i° Case. — Madame B., set. 33 years, enjoying good health, 
was confined three times under normal conditions. 

During a new pregnancy, the midwife being called in, Jan. 
nth, 1876, diagnosed a presentation of the shoulder, and I con- 
firmed the diagnosis on the same day. The head was upon the 
left side and the back in front. I pushed the head towards the 
superior strait and held it there with my hand, but it resumed 
its former position as soon as I ceased the pressure. 

The same manoeuvre was repeated on the 17th with the same 
result. Labor commenced on the 19th, a. m. Having placed 
the woman in the left lateral decubitus, I again pushed the head 
into the superior strait, where the midwife held it, particularly 
at the commencement of each pain. At 1 1 p. M. the child was 
born spontaneously, vertex presenting ; it was covered by the 
caul and the liquor amnii did not escape until the head was de- 
livered. 

2° Case. — Madame F., wife of a cigar maker, was naturally 
delivered of six children. During her seventh pfregnancy, in 

1. Schroeder, loco citato. 

l Z. Amer. Jour, of Obstetrics, April, 1877. 



94 

February, 1876, the midwife diagnosed a transverse presenta- 
tion. I easily performed version by external manoeuvres, and 
conducted the head to the superior strait. For three weeks 
the operation was repeated once a week with the same result, 
viz., as soon as the woman would assume the upright position, 
the foetus would resume the transverse. 

After numerous examinations, I could precisely determine 
which extremity was the breech and which the head, and this 
had for some time been doubtful. 

March 7th, 1876 — 6 a. m. The membranes ruptured. I was 
called at 1 p. M. and found the head a little more to the left ; 
having pushed it toward the superior strait I had it held there 
by the midwife and husband alternately. The child was born 
alive without the intervention of art." 

Finally, in order to omit nothing concerning the subject 
which now occupies our attention, I shall still give another ex- 
ample recorded in the thesis of Dr. Real, which case by adding 
to the numerous means employed to correct mal -presentations, 
again testifies in favor of the efforts directed towards the attain- 
ment of the desired object. 

A case of preve?itive treatment of trunk presentation 
followed by success. (1) 

Madame B., was delivered in January and December, each time 
of a boy. In both instances there was a presentation of the 
trunk. Version was difficult and prolonged and the children 
perished. The mother escaped all dangers in these laborious 
confinements. In 1847, Madame B. again became pregnant, 
and the fear of the terrible experiences which she had previously 
suffered, caused her husband, an intelligent and prudent man, 
to consult me immediately, with a view to know if it were pos- 
sible to adopt any means to prevent the repetition of the same 
misfortune. 

Although I did not find any preventive against trunk pre- 
sentations in the authors, I was still convinced that the mal- 
presentation in this woman could not be attributed to chance, 
especially in view of the fact that there were many other cases 

1. Louis Real's Thesis, Paris, 1852. 



95 

in which it had been reproduced, even as often as five times, ac- 
cording to the report of M. Naegele. Therefore, considering 
this result to be due to certain organic dispositions, which 
doubtless would not fail to cause the same effect again in 
Madame B., I sought what might be the presumable cause, in 
order to try to employ the proper remedy. This was my 
opinion, and in virtue of it I soon instituted a combination of 
prophylactic measures. I admit the most probable of all to be 
the opinion that the foetus arranges itself in the uterine cavity 
in that position which is easiest for it to assume in its 
smooth sac, so that the largest diarm ters of the body contained 
are naturally found in relation with the largest diameters of the 
body containing. Under this general expression of "body con- 
taining," we should understand all those abdominal organs 
whose walls may have an influence upon the foetus, and espec- 
ially should we understand the uterus itself. 

This being established, we can readily conceive how a trunk 
presentation may be caused by a relative diminution in the ver- 
tical diameter of the abdomen, or still better, by a greater ten- 
dency of the uterus to develop laterally rather than vertically. 

The first condition was found in Madame B., who was small 
while her children were large. Our efforts were then directed 
towards preventing the excessive lateral development of the 
uterus and at the same time to allow it all necessary space for 
its vertical enlargement. As I could not precisely determine 
the time when the influence of the lateral development of the 
uterus would be most manifested, as soon as I could distinctly 
palpate the organ above the pubis, I advised the use of a 
double binder with compresses, by means of which transverse 
pressure could be made over the lateral walls of the uterus. 

In proportion to the advancement of the gestation, was the 
size of the compresses increased, but this was soon stopped and 
we confined our efforts to merely applying the binder quite 
firmly over the lateral compresses. These compresses were 
made large enough to render, by lateral compression the antero- 
posterior diameter of the abdomen greater than the transverse. 
This binder remained in position even during the night, until 
the termination of pregnancy. In order to aid the action of 
this mechanical means ; I strongly insisted that Madame B. 



9 6 

should not bend over, either in 'sitting or stooping 1 , for fear of 
forcing the foetus to abandon its favorable position, whence, 
perhaps, we could only with difficulty dislodge it. During the 
entire course of her pregnancy, Madame B. also made use of an 
arm chair having a strongly inclined back. 

Success crowned our efforts, for she w.»s happily delivered, 
May 1 8th, 1848, of a boy who presented by the vertex." 

We believe it would be difficult to deny the action of the 
mechanical means which were here employed. 

Thus it has been advised from the very beginning of the 
present century, to maintain the foetus in the situation we have 
caused it to assume by the dorsal or lateral decubitus, immobil- 
ity, lateral compression, rupture of the membranes, ergot, simple 
application of the binder, a bandage p rovided with compresses, 
a bandage provided with a double compress, and finally con- 
stant compression made over the head either by the hands of 
the midwife or by those of the husband. (Ellinger.) 

Generally when the means extolled for procuring one and 
the same object are so numerous and varied, it, as a rule, 
proves that the best means is still to be found. Is it thus in 
the present instance ? I believe so. 



NEW METHOD FOR DEFINITELY TRANSFORMING MAL-PRE- 
SENTATIONS INTO VERTEX PRESENTATIONS. 



After studying for a long time the accommodation of the 
foetus, and I believe recognizing its causes and discerning the 
degree of influence of these causes, it was easy for me to go a 
step farther than Wigand, by observing nature, and trying to 
imitate her not only at the moment of labor, but also during 
gestation. 

Appreciating an important fact, which had been proved by a 
number of clinical observations and statistics, that multiparity 
is by far the most frequent cause of mal-presentations, it 
became necessary to find the reason. 

This problem, on the whole, was simple and easy to solve ; it 
sufficed to consider it in the following manner. 



97 

A woman well-formed, both as regards hard and soft parts, 
is confined several times at full term with children equally 
well-formed, but in proportion as the number of pregnancies 
increase, the tendency to mal-presentations becomes more and 
more manifest. What is the cause ? 

A little reasoning soon shows that if the ovum be normal, 
that is to say, if the foetus be well developed and well formed, 
the quantity of liquor amnii neither too little nor too great, the 
placenta normally inserted, whatever alterations occur under 
these conditions, must reside in the maternal organization. 

Attention being therefore directed exclusively to the mother, 
the bony structures not being altered are soon eliminated, and 
there only remain the soft parts for consideration. They are 
in effect the only structures upon which each pregnancy im- 
presses indelible marks as regards appearance, form, and consis- 
tence. We have then only to determine what are the modifi- 
cations of these parts, which give rise to the disposition to 
mal-presentations. For this purpose it is only necessary to 
examine the walls of the two cavities, viz : the uterine and 
abdominal, in which the foetus and the gravid uterus develop. 

Being brought to this conclusion by such reasoning, 1 then 
had recourse to the clinic to elucidate this last factor in the 
question. The great number of examinations which I was 
able to make upon women in different periods of gestation, 
demonstrated what was already well known, viz : that in pri- 
miparae the foetus at the age of 7 or 8 mos. contracts definite 
relations with the pelvic excavation, while "on the contrary in 
multiparas until the very last term of pregnancy it moves with 
more or less facility above the superior strait. 

From this time forth the reason of this difference was manifest. 

In as much as all the factors of accommodation existing in the 
foetus were normal, I had to conclude that the maternal factors 
must be more or less at fault, and among these latter, it was 
the element of form which suffered the most profound im- 
pression. 

Two causes concur to make the uterine cavity lose its normal 
shape by successively repeated labors : the changes in its own 
wall and those in the abdominal wall. 

As the uterus after labor and during involution undergoes 



a sort of renovation, it is probable that when its walls are dis- 
tended by a new pregnancy, they do not offer the same toni- 
city or the same elasticity as formerly, and in a word lose more 
or less their special property of preserving the form of the 
organ. 

Perhaps their thickness is also diminished ; but this point is 
not completely elucidated. This is the first condition then, 
that renders the tendency to uterine accommodation less pro- 
nounced, (see Accommodation?) 

On the other hand the abdominal wall also undergoes pro- 
found modifications with each succeeding pregnancy. The 
muscles experience an elongation, an alteration in relation, the 
fibro-aponeuratic membranes are stretched and the return to 
their primitive condition is never perfectly accomplished. 

In effect, the abdominal cavity becomes more spacious with 
each pregnancy. 

"The muscular walls that clasp the full term uterus upon 
nearly every side" (i), no longer adapts itself to the organ so 
accurately, but holds it only feebly, and allowing for it such 
large space, does not force it to descend deeper into the pelvic 
cavity. 

Thence, the non or incomplete accommodation shows itself 
by the more or less pronounced tendency to mal-presentations 
or by the absence of any fixed presentation at all. 

Being convinced of these facts, I determined to give to the 
abdominal wall the power which it lacked, and to the uterine 
wall the support which it needed. For this object I had made 
by M. Raoul Mathieu a bandage of which the following is a 
description. 

This bandage is composed of three pieces : 
a right and left lateral piece forming the body of the bandage, 
and an intermediate piece forming the anterior part. 

The posterior P and anterior T parts are of strong whale- 
bone, joined together laterally by an elastic C and posteriorly by 
buckles and straps, to tighten or loosen the bandage according 
to the size of the abdomen. The front is laced together 



1. Dubois and Pajot. Traite complet de Part des accouchements, 411. 



99 




Fig. 28. Bandage applied : lateral view. 




Fig. 29. Bandage applied : front view. 



IOO 

crosswise over American eyelets. The piece B is of whale-bone 
covered with flannel, and is applied over the abdominal wall 
before the bandage is permanently fixed ; this completes the 
bandage, both preventing the hard contact of the lacing with 
the skin and rendering a strong compression supportable. 
The thigh-straps are put on to prevent the bandage from 
riding up over the abdomen. 

When should this bandage be applied \ and to what cases is 
it applicable? 

In a woman 8 months pregnant, if the head be not engaged 
in the pelvic excavation, the bandage should be applied. If 
there be a presentation of the breech or shoulder, version 
should be performed, the head turned below and the bandage 
immediately applied. It is necessary that the bandage be 
passed under the flanks of the woman before version is per- 
formed, for sometimes as I have observed with M. Tarnier, after 
the head is turned to the plane of the superior strait, the effort 
made by the woman to raise herself up, suffices to reproduce 
the mal-presentation. We should, then, before fixing the ban- 
dage, be well assured that the head is above the excavation. 
During the first day the compression should be moderate ; we 
make the compression constant and uniform during the suc- 
ceeding days by strapping the bandage tighter behind ; this is 
necessary on account of the elasticity of the rubber and also of 
the accommodation of the fcetus. 

In every case where the bandage has been applied, it has 
been perfectly well borne. Generally a decided relief is experi- 
enced in consequence of its use. There has never resulted any 
trouble either to the mother or the child. 

The bandage may be removed before labor if the head sinks 
into the excavation ; but if the head rests on the plane of 
the superior strait it should be removed only when the os is 
completely dilated and the membranes ruptured. 

Thus, you observe. I not only apply the bandage after per- 
forming version by external manoeuvres, but also during the 
eighth month of pregnancy, even if the head be below, pro- 
viding there be no pelvic accommodation. 

I believe, that in bringing about a complete accommodation 
during gestation by this means, we may cause the various pro- 



IOI 

lapses of the extremities and of the cord, as also face presen- 
tations to disappear. I will also here repeat what I said before 
the Medical Society of Public and Professional Hygiene, (i) 

" I think that a new chapter should be added to those already 
known concerning pregnancy. I believe that we should exam- 
ine during the latter months of gestation, if the child be 
accommodated, if the presentation be favorable, if there be a 
mai-presentation, in order that we may then and there correct 
it. In a word : if during the latter months of gestation the 
head of the foetus be not in the excavation, we should place it 
there. 

Unless I am mistaken, we can in all cases prevent presenta- 
tions of the shoulder, of the breech and of the face, of which 
we all know the deplorable consequences. Just as women are 
vaccinated and re-vaccinated in order to escape variola, so should 
they likewise be examined in order not to expose themselves or 
their offspring to that dreadful operation of internal podalic 
version. The means which we now employ to make this ex- 
amination, and correct the abnormal situations of the fcetus in 
utero, are neither more painful nor more repugnant than those 
used in the performance of vaccination." 

When I communicated my memoir to the Chirurgical So- 
ciety, I had only a very limited number of cases. I am now 
happy to offer a much greater number, thanks to the assistance 
of my teachers and friends, whom I here beg to accept this 
expression of my deepest gratitude. 

True it is, indeed, that even by adopting this methed and 
always producing vertex presentations, I have no right to say 
that I have entirely prevented the occurrence of mal -presenta- 
tions, since in a certain number of cases, nature at the very 
moment of labor would have produced the same result, but at 
all events I have made it a certainty, and if by these means 
some lives may be saved, I will indeed be largely recompensed. 

Here follows a graphic record of 23 cases to prove the effi- 
cacy of the foregoing. 

1. "Recent considerations upon the hygiene of pregnancy." 

Bulletin de la Societe de mtdecine pubtique et professionnelle. T. I. 1877. 



ERRATA. 

Page 9, line 10 — Read : since the gravid, &c. 

" 45 — The two lines below fig. 24 should be above it. 

" 71 — Line 6 from bottom : Tarnier. 

" 98, line 17 — Read : the muscular wall that clasps, &c. 



